Chapter 47: Acetabulum Fractures

Berton R. Moed, Mark C. Reilly

Chapter Outline

Introduction to Acetabulum Fractures

Since the advent of mandatory seatbelt use, there has been a significant reduction in the number of acetabular fractures and the complexity of the fractures has decreased.2 From data available from the United Kingdom obtained after the enactment of mandatory seatbelt legislation in 1983, the overall incidence of acetabular fractures is approximately 3 patients/100,000/year and has remained stable over the past few decades.91 Essentially, there has been minimal or no change in the number of fractures caused by motor vehicle accidents and falls from a height >10 feet; however, those resulting from falls from a height <10 feet has increased.91 In addition, the mean age of patients sustaining fractures of the acetabulum appears to be increasing.46,91 In the elderly patient (defined as more than 60 years of age), the most common mechanism of injury is a fall, as opposed to the situation for a younger patient, in whom a motor vehicle accident is the most common.46 This circumstance is consistent with the fact that the elderly patient more commonly presents with an acetabular fracture as an isolated injury.46 
From a historical perspective, the literature from the 1950s and 1960s offered conflicting recommendations regarding the optimal care for a fracture of the acetabulum.86,156 Both nonoperative and operative treatment regimens were purported to be the best. However, much of the confusion in management recommendations can be attributed to the fact that there was no comprehensive or accepted acetabular fracture classification, an unsatisfactory situation that was well recognized even at that time.173 Each investigator reporting on any sizable number of cases produced his or her own method to describe the fracture. Fracture evaluation was further complicated by the fact that in most instances radiographic assessment was limited to a single anteroposterior (AP) pelvic view. Not unexpectedly, it was stated at the time that “the surgeon must not be surprised if, even after careful study, his preconceived idea of a given fracture does not exactly fit the findings at operation.”86 However, there was some consistency amid the apparently disparate recommendations: All these early investigators did agree that poor results would follow from a hip injury that resulted in either joint instability or a femoral head that was incongruent with the weight-bearing dome.86,156,172,173 
Judet et al.78 provided more clarity to this confused situation. In their 1964 treatise, they set out to describe, among other things, the radiographic findings in acetabular fracture patients and to outline a plan of treatment. Their recommendation for operative treatment was based on 10 years of study and resulted from their disappointment with the results of nonoperative methods.78 Over the next three decades, they refined a number of aspects presented in this seminal publication.93 However, the basic concepts remain, including understanding the surgical anatomy of the innominate bone, defining the injury via appropriate radiographic assessment, and, by these means, determining a suitable treatment plan. 
The further studies by Letournel and Judet93 and by Matta107 have shown that to attain the best results, hip joint congruity and stability must be accompanied by an anatomic (defined as less than 2 mm of residual displacement) reduction of the displaced articular surface. Therefore, accurate reduction of the intra-articular fracture fragments is critical for a successful outcome, as is maintenance of this reduction by internal fixation. It has been stressed that in a displaced fracture this anatomic reduction is very difficult to obtain by closed means.108,111 In addition, standard plate and screw fixation constructs, which require open surgery, have been shown to be stronger than their percutaneous counterparts, demonstrating greater yield strength and maximal load at failure.30 Therefore, open anatomic reduction and internal fixation continue to serve as the mainstays in the treatment of displaced fractures of the acetabulum (Fig. 47-1). However, evidence is mounting in support of treating elderly patients (defined as patients aged 60 and older) using minimally invasive reduction and percutaneous fixation.48,49 
Figure 47-1
 
A: Anteroposterior (AP) radiograph in traction of a 42-year-old man at the time of transfer to our center, 3 weeks after sustaining a displaced transverse right acetabular fracture in a motor vehicle accident. Subsequently, open reduction and internal fixation was performed. B: AP radiograph at his 20-year follow-up examination. The patient had returned to full activities within 1 year of his accident and continued to be asymptomatic regarding the right hip.
 
(Copyright Berton R. Moed, MD.)
A: Anteroposterior (AP) radiograph in traction of a 42-year-old man at the time of transfer to our center, 3 weeks after sustaining a displaced transverse right acetabular fracture in a motor vehicle accident. Subsequently, open reduction and internal fixation was performed. B: AP radiograph at his 20-year follow-up examination. The patient had returned to full activities within 1 year of his accident and continued to be asymptomatic regarding the right hip.
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Figure 47-1
A: Anteroposterior (AP) radiograph in traction of a 42-year-old man at the time of transfer to our center, 3 weeks after sustaining a displaced transverse right acetabular fracture in a motor vehicle accident. Subsequently, open reduction and internal fixation was performed. B: AP radiograph at his 20-year follow-up examination. The patient had returned to full activities within 1 year of his accident and continued to be asymptomatic regarding the right hip.
(Copyright Berton R. Moed, MD.)
A: Anteroposterior (AP) radiograph in traction of a 42-year-old man at the time of transfer to our center, 3 weeks after sustaining a displaced transverse right acetabular fracture in a motor vehicle accident. Subsequently, open reduction and internal fixation was performed. B: AP radiograph at his 20-year follow-up examination. The patient had returned to full activities within 1 year of his accident and continued to be asymptomatic regarding the right hip.
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One could contend that since Letournel and Judet93 published their definitive text in 1993, there has been little in the way of new information regarding acetabular fracture care. Their results are still considered the “gold standard” of what can be obtained in the treatment of these difficult injuries. However, there are some new trends that have developed over the past 5 to 10 years, most of which serve to expand on principles advocated by Letournel and Judet. Such trends include the advancements in perioperative imaging. In the 1960s, Judet et al.78 recognized that the plane of the ilium was approximately 90 degrees to the plane of the obturator foramen and that both of these structures were oriented roughly 45 degrees to the frontal plane. Therefore, they proposed that the AP pelvis and two 45-degree oblique views be used to study the radiographic anatomy of the acetabulum.78 After understanding the radiographic landmarks on the intact dry innominate bone, these landmarks could then be appropriately analyzed in fracture cases and from this process came the first systematic classification of acetabular fractures, based on the anatomic pattern of the fracture.78 In the 1993 text, this analysis was expanded to include preoperative two-dimensional computed tomography (CT).93 Subsequent advances in CT technology have not only improved the information provided by the two-dimensional images but also now offer the promise of useful three-dimensional images as well as computer-generated plain radiograph-like images created from the CT data.17,89,141 Intraoperative imaging has evolved from plain radiographs to C-arm image intensifier fluoroscopy to the promise of three-dimensional imaging with image-guided surgical navigation. Postoperative CT, once considered unnecessary, became accepted as an important evaluative tool at many centers.120 Nonetheless, concerns exist regarding the additional radiation exposure from a second pelvic CT, as small individual cancer risks applied to an increasingly large population may create a public health issue some years in the future.21,191 However, the individual risk to an adult patient from a CT study is very low.21,89 To put this in perspective, for any one person in the United States population, the risk of radiation-induced fatal cancer is much smaller (less than 1 in 2,000) than the person’s natural risk of getting cancer (1 in 5).191 When any CT scan is required for medical need, the associated risk is very small relative to the diagnostic information obtained.21 
Although the surgical approaches to the acetabulum described by Letournel and Judet continue as the “gold standards,” the availability of useful alternative approaches has expanded over time. In addition, the manner in which perioperative complications, such as deep vein thrombosis, are managed has evolved. Perhaps the most controversial trend, however, is that toward percutaneous fracture reduction and fixation techniques.48,49,168 No matter what the method, obtaining an excellent long-term result in the treatment of a fracture of the acetabulum is dependent on restoring a congruent and stable hip joint with an anatomically reduced articular surface. As has been noted, these treatment objectives have been well recognized for more than half a century. The achievement of these objectives should minimize pain, prevent posttraumatic osteoarthritis, and thereby improve long-term functional outcome. However, fractures of the acetabulum continue to be a challenge for the orthopedic surgeon. Successful treatment of an acetabular fracture is based on a thorough understanding of the complex three-dimensional anatomy of the innominate bone.78,93 Although certain fracture patterns may not require surgery to have a satisfactory outcome, in general, those with hip instability, hip incongruity, or fracture displacement in the superior weight-bearing area of the acetabulum should be managed with open reduction and internal fixation. The surgery is complex and demanding even for the experienced surgeon, and has the potential for many serious complications. Many factors, including the patient’s age, general medical condition, and associated injuries, must be considered before making definitive management decisions.145 Therefore, the operative treatment of these fractures is best performed by specialized surgeons who routinely care for patients with these injuries.38,79,91,142,144 All orthopedic surgeons, however, should be capable in the diagnosis of these fractures and able to determine which may require surgical management. 

Assessment of Acetabulum Fractures

Mechanisms of Injury for Acetabulum Fractures

Fractures of the acetabulum occur by impact of the femoral head with the acetabular articular surface.78 This force to the femoral head may be applied via the greater trochanter (along the axis of the femoral neck) or from anywhere along the long axis of the femoral shaft. Subsequently, the pattern of the resulting acetabular fracture depends on the position of the hip at the time of impact, as well as the location and direction of the originally applied force (Table 47-1).93 With the force applied along the axis of the femoral neck, external hip rotation will produce an anterior fracture type and internal rotation will produce a posterior fracture (Fig. 47-2). In general, a force applied along the axis of the femur, when the hip is flexed, drives the femoral head against the posterior articular surface of the acetabulum. However, with the addition of adduction, the femoral head may dislocate without causing a fracture. Whatever the hip position or location of the applied force, however, the degree of fracture displacement, fracture comminution, and articular impaction further depend on the magnitude of the applied force as well as the strength of the underlying bone. Despite sustaining a relatively low-energy injury, patients with osteopenic bone often sustain severely comminuted fractures with articular impaction. A simple fall on the greater trochanter may cause an acetabular fracture in the older, osteopenic patient. It is not surprising, then, that the fracture types most commonly sustained by the elderly are those involving the anterior column and/or wall, which are caused by a fall on the greater trochanter (Table 47-1).46 These relatively low-energy injuries usually produce isolated fracture, whereas high-energy injuries are often associated with additional skeletal or other system trauma.46,91 
Figure 47-2
The type of acetabular fracture depends, in part, on the rotational position of the femoral head at the time of impact.
 
With the force applied along the femoral neck, external rotation will produce an anterior fracture (striped arrow) and internal rotation will produce a posterior fracture (solid arrow).
With the force applied along the femoral neck, external rotation will produce an anterior fracture (striped arrow) and internal rotation will produce a posterior fracture (solid arrow).
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Figure 47-2
The type of acetabular fracture depends, in part, on the rotational position of the femoral head at the time of impact.
With the force applied along the femoral neck, external rotation will produce an anterior fracture (striped arrow) and internal rotation will produce a posterior fracture (solid arrow).
With the force applied along the femoral neck, external rotation will produce an anterior fracture (striped arrow) and internal rotation will produce a posterior fracture (solid arrow).
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Table 47-1
Force Applied and Hip Position Versus Fracture Pattern
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Table 47-1
Force Applied and Hip Position Versus Fracture Pattern
Applied Force Hip Abduction/Adduction Position Hip Rotation Position Fracture Pattern
Along the axis of femoral neck (on the greater trochanter) Neutral
Neutral
Neutral
Neutral
Neutral
Adduction
Abduction
Neutral
25 degrees ERa
50 degrees ERa
20 degrees IRb
50 degrees IRb
20 degrees IRb
20 degrees IRb
Anterior column (or wall) and posterior hemitransverse (AC + PHT)
Anterior column
Anterior wall
Variable: Transverse, T-shaped, or both-column
Posterior column plus complete or incomplete transverse component
Transtectal transverse
Juxtatectal/infratectal transverse
Along the axis of femoral shaft (hip flexed 90 degrees) Neutral
Abduction 50 degrees
Abduction 15 degrees
Adduction
Any
Any
Any
Any
Posterior wall ± hip dislocation
Transverse
Posterior column
Posterior hip dislocation ± posterior wall fracture
Along the axis of femoral shaft (hip extended) Neutral
Abduction
Any
Any
Posterior superior fracture of the posterior wall
Transtectal transverse
X

Associated Injuries with Acetabular Fractures

Fractures of the acetabulum are frequently associated with other musculoskeletal and visceral injuries. In some series, such associated injuries occurred in more than 50% of patients.88,107,122,131 Overall, in the large series reported by Matta,107 35% of the acetabular fractures were associated with an injury involving an extremity, 19% with a head injury, 18% with a chest injury, 13% with a nerve palsy, 8% with an abdominal injury, 6% with a genitourinary injury, and 4% with an injury of the spine. In a more recent study, lower extremity fracture was found to be the most commonly associated injury (36%), followed by injuries to the lungs, retroperitoneum, and upper extremities (respectively ranging from 21% to 26%). Other injuries occurred, in increasing order, to the bowel, kidney, vascular system, bladder, spleen, liver, brain, and spine (respectively ranging from 2% to 16%).148 Despite a somewhat lower rate reported in the elderly acetabular fracture patient, associated injuries still occur in 30% of these patients.46 Even isolated fractures of the acetabulum often require blood replacement, reported to be 35% in one series.101 Consequently, the initial evaluation, even in those patients with an apparent isolated injury, should be part of a well-organized overall approach. Associated injuries can be life- or limb-threatening and the recommended Advanced Trauma Life Support (ATLS) evaluation sequence should be followed.3 
Disruption of the pelvic ring may occur in association with a fracture of the acetabulum. This pelvic injury may be an important factor regarding the patient’s hemodynamic status at the time of initial presentation.159 In addition, the pelvic ring injury may alter subsequent acetabulum fracture care. Contralateral rami fractures may affect the surgeon’s decision to use intraoperative traction. For example, the use of a peroneal post in the presence of rami fractures may be a deforming force on certain acetabular fractures and possibly prevent reduction.93 A posterior pelvic ring disruption usually must be reduced and stabilized, re-creating a stable posterior fixation point, prior to surgical treatment of most acetabulum fractures.93 If a slight malreduction of the posterior ring injury may preclude an anatomic acetabular fracture reduction, as is the situation when the acetabular fracture (such as a transverse fracture type) itself constitutes the concomitant “anterior ring” injury, the order of fixation is often reversed. 
In contradistinction to the unstable pelvic ring injury, a closed fracture of the acetabulum, occurring alone or in combination with other extremity fractures, should not be presumed to be the primary cause of hypotensive shock. An alternative source of hemorrhage should always be sought. However, laceration of the superior gluteal artery with severe bleeding can be caused by fractures of the acetabulum having wide posterior column displacement. One must be alert to this possibility, which is treatable by therapeutic embolization (Fig. 47-3). The acute evaluation and treatment of these serious life- and limb-threatening injuries take precedence over the acetabular fracture management. However, an orthopedic surgeon must be involved early on, as initial management of associated injuries often will affect the future acetabular fracture care. Simple measures may prove to be very important, such as locating a suprapubic catheter or colostomy so as not to preclude a later planned surgical approach to the acetabulum. As previously noted, the injuring force can be applied either directly to the region of the hip or indirectly along the axis of the femur. Therefore, associated injuries can occur locally about the hip, distal to the hip at the location of the applied axial load, or anywhere in between. These injuries can be occult and great care must be taken during the initial examination and diagnostic evaluation of the patient to elucidate their presence or absence. Fractures involving some aspect of the femur or knee are common. The initial management of these fractures often affects the later treatment of the acetabular fracture. Therefore, it is important to develop treatment strategies that achieve the best result for all associated injuries. A displaced fracture of the femoral head may be present, especially in association with a posterior fracture-dislocation.88 These fractures are usually treated at the time of acetabular fracture fixation (Fig. 47-4). 
Figure 47-3
 
A 36-year-old female unrestrained driver involved in a motor vehicle accident sustained a fracture of the acetabulum (A) with wide displacement and a particularly sharp spike of posterior column at the greater sciatic notch (arrow), became hemodynamically unstable shortly after presentation to the emergency department. Subsequent evaluation including angiography (B) revealed a superior gluteal artery injury to be the source of the bleeding, which was successfully treated by embolization (arrow). (Copyright Berton R. Moed, MD.)
A 36-year-old female unrestrained driver involved in a motor vehicle accident sustained a fracture of the acetabulum (A) with wide displacement and a particularly sharp spike of posterior column at the greater sciatic notch (arrow), became hemodynamically unstable shortly after presentation to the emergency department. Subsequent evaluation including angiography (B) revealed a superior gluteal artery injury to be the source of the bleeding, which was successfully treated by embolization (arrow). (Copyright Berton R. Moed, MD.)
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Figure 47-3
A 36-year-old female unrestrained driver involved in a motor vehicle accident sustained a fracture of the acetabulum (A) with wide displacement and a particularly sharp spike of posterior column at the greater sciatic notch (arrow), became hemodynamically unstable shortly after presentation to the emergency department. Subsequent evaluation including angiography (B) revealed a superior gluteal artery injury to be the source of the bleeding, which was successfully treated by embolization (arrow). (Copyright Berton R. Moed, MD.)
A 36-year-old female unrestrained driver involved in a motor vehicle accident sustained a fracture of the acetabulum (A) with wide displacement and a particularly sharp spike of posterior column at the greater sciatic notch (arrow), became hemodynamically unstable shortly after presentation to the emergency department. Subsequent evaluation including angiography (B) revealed a superior gluteal artery injury to be the source of the bleeding, which was successfully treated by embolization (arrow). (Copyright Berton R. Moed, MD.)
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Figure 47-4
A 55-year-old obese woman involved in a motor vehicle accident had a right acetabular fracture and a history of hip dislocation.
 
An intraoperative fluoroscopic view (A) prior to surgical intervention shows a femoral head fracture (arrows), a small posterior wall fracture (arrowhead), and a subluxated hip joint. The intraoperative fluoroscopic view (B) after reduction and fixation of both fractures, performed at the same operative intervention using a trochanteric flip osteotomy surgical approach41,44 is shown prior to reattachment of the trochanteric osteotomy.
 
(Copyright Berton R. Moed, MD.)
An intraoperative fluoroscopic view (A) prior to surgical intervention shows a femoral head fracture (arrows), a small posterior wall fracture (arrowhead), and a subluxated hip joint. The intraoperative fluoroscopic view (B) after reduction and fixation of both fractures, performed at the same operative intervention using a trochanteric flip osteotomy surgical approach41,44 is shown prior to reattachment of the trochanteric osteotomy.
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Figure 47-4
A 55-year-old obese woman involved in a motor vehicle accident had a right acetabular fracture and a history of hip dislocation.
An intraoperative fluoroscopic view (A) prior to surgical intervention shows a femoral head fracture (arrows), a small posterior wall fracture (arrowhead), and a subluxated hip joint. The intraoperative fluoroscopic view (B) after reduction and fixation of both fractures, performed at the same operative intervention using a trochanteric flip osteotomy surgical approach41,44 is shown prior to reattachment of the trochanteric osteotomy.
(Copyright Berton R. Moed, MD.)
An intraoperative fluoroscopic view (A) prior to surgical intervention shows a femoral head fracture (arrows), a small posterior wall fracture (arrowhead), and a subluxated hip joint. The intraoperative fluoroscopic view (B) after reduction and fixation of both fractures, performed at the same operative intervention using a trochanteric flip osteotomy surgical approach41,44 is shown prior to reattachment of the trochanteric osteotomy.
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Associated fractures of the proximal femur can present a dilemma, as initial femur fracture treatment may compromise the optimal surgical approach to the acetabulum. Options include treating these fractures at the time of acetabular fracture fixation or planning the staged surgical procedures so as not to interfere with optimal acetabular fracture care. A femoral neck fracture in a young adult patient, generally defined as those younger than 65 years, should be treated surgically on an urgent basis.99 In this situation, it would be unusual to treat the associated acetabular fracture at the same time.88 If open reduction and internal fixation, rather than closed reduction and percutaneous fixation, is required for treatment of the femoral neck fracture, a Watson-Jones anterolateral approach is preferred.99,188 Alternatively, a modified Smith-Petersen anterior surgical approach can be used.136 Although the modified Smith-Petersen approach allows direct access to the femoral neck fracture, a separate incision is required for implant insertion.136,188 The acetabular fracture can then be addressed later, as required, preferably through a separate, optimal approach. Unfortunately, it may be unavoidable that the optimal surgical approach for femoral neck fracture treatment will compromise the optimal approach for the acetabulum. In this situation, one must choose between treating both fractures at the same operative setting and staging the acetabulum fracture fixation to follow acceptable healing of the femoral neck fracture fixation wound. In contradistinction to the femoral neck fracture in a young adult, intertrochanteric and subtrochanteric femur fractures do not need to be operatively treated in an urgent fashion. Therefore, the treating physician has the luxury of choosing either staged fixation of the proximal femur fracture followed later, after wound healing, by fixation of the acetabular fracture or appropriately timed delayed fixation of both fractures during the same operative setting using the same or separate incisions. In either case, the treatment scheme should be planned in a way to optimize treatment of the acetabular fracture. 
Antegrade interlocked intramedullary nailing with reaming has been shown to be an effective method for the management of fractures of the femoral shaft. Considered the treatment of choice for the majority of these fractures, its advantages include a rate of fracture union approximating 98%, infrequent malunion, and a low prevalence of infection.24,193195 However, this surgical technique is not without its disadvantages, including its potentially limited applicability in the treatment of the femoral shaft fracture occurring in association with an ipsilateral acetabulum fracture.130 In general, with this combination of injuries, the femoral fracture is stabilized first. If the femoral shaft fracture and acetabular fractures are to be fixed in a staged fashion, once again, the treatment scheme should be planned in a way to optimize treatment of the acetabular fracture. If the incision for antegrade nailing will compromise the optimal surgical approach to the acetabulum, an alternative femoral shaft fracture treatment method should be selected, such as retrograde nailing (Fig. 47-5). When the femoral shaft and acetabular fractures are addressed as sequential procedures during the same anesthesia, antegrade femoral nailing still may not be the best choice. Compromised access to the proximal femur, which may occur with a severely displaced associated both-column fracture, or an irreducible dislocation of the femoral head that precludes satisfactory femoral shaft fracture reduction are two such situations. Alternatives include plating or retrograde nailing. 
Figure 47-5
An 18-year-old 176.9-kg (390-lb) man (A) was involved in a motor vehicle accident.
 
Anteroposterior radiograph (B) of the hip and selected two-dimensional computed tomography section (C) show a T-shaped fracture of the acetabulum and an ipsilateral fracture of the femoral shaft (D). Retrograde nailing was used to stabilize the femur (E) followed by acetabular fixation 2 days later (F) using the Kocher–Langenbeck approach.
 
(Copyright Berton R. Moed, MD.)
Anteroposterior radiograph (B) of the hip and selected two-dimensional computed tomography section (C) show a T-shaped fracture of the acetabulum and an ipsilateral fracture of the femoral shaft (D). Retrograde nailing was used to stabilize the femur (E) followed by acetabular fixation 2 days later (F) using the Kocher–Langenbeck approach.
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Figure 47-5
An 18-year-old 176.9-kg (390-lb) man (A) was involved in a motor vehicle accident.
Anteroposterior radiograph (B) of the hip and selected two-dimensional computed tomography section (C) show a T-shaped fracture of the acetabulum and an ipsilateral fracture of the femoral shaft (D). Retrograde nailing was used to stabilize the femur (E) followed by acetabular fixation 2 days later (F) using the Kocher–Langenbeck approach.
(Copyright Berton R. Moed, MD.)
Anteroposterior radiograph (B) of the hip and selected two-dimensional computed tomography section (C) show a T-shaped fracture of the acetabulum and an ipsilateral fracture of the femoral shaft (D). Retrograde nailing was used to stabilize the femur (E) followed by acetabular fixation 2 days later (F) using the Kocher–Langenbeck approach.
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Axial loading through the lower extremity by impact of a flexed knee on an automobile dashboard is a common cause of acetabular fracture. Therefore, the knee must always be carefully evaluated for instability, especially involving the posterior cruciate ligament.161 Often, this examination is difficult or limited because of patient discomfort and an inability to cooperate because of the acetabular fracture. In this situation, the knee should be examined under anesthesia at the conclusion of any required hip surgery. Although magnetic resonance imaging (MRI) of the knee has been advocated for all patients with traumatic hip dislocation,161 the clinical importance of MRI findings not suspected from the initial physical examination remains in doubt. Inability to perform an adequate knee examination or continued knee symptoms in absence of clinical findings indicate further evaluation is needed, such as MRI. 
Neurologic injury involving the ipsilateral lower extremity occurs in up to 30% of patients with acetabular fractures.74,93 Injury of the sciatic nerve is most common and is usually partial in nature.45,74,93,121 Other peripheral nerves, such as the femoral, obturator, and superior gluteal nerves, may also be injured.58,93 However, the true prevalence of these posttraumatic nerve injuries is most likely underestimated.58,93 The prognosis for functional recovery of a sciatic nerve injury is variable, depending on the degree of involvement of the peroneal division. Complete or nearly complete motor and sensory recovery of an injured tibial division can be expected in the majority of patients.45 However, patients with a severe injury of the peroneal division, in isolation or in association with an injury of the tibial division, cannot be expected to recover good function.45 Traumatic injury to the femoral nerve in association with a fracture of the acetabulum is rare, having a prevalence of 0.2%, and unless the nerve has been transected, recovery of function can usually be expected to occur.58,63 Although the superior gluteal nerve and obturator nerves are particularly at risk with some fracture patterns, it can be impossible to assess their function in a patient with an acute fracture. Therefore, the prevalence of their traumatic injury and subsequent functional recovery are yet to be determined. 

Signs and Symptoms of Acetabular Fractures

The patient history related to acetabular fracture trauma is often very helpful, especially when determining the specific cause of injury. As previously noted, in most cases, the patient with a fracture of the acetabulum has sustained high-energy trauma and these patients often will have an associated injury that must be identified during the initial work-up. The pattern of the acetabular fracture depends on the position of the hip at the time of impact, as well as the location and magnitude of the applied force (see Table 47-1). The information provided may indicate a history of axial loading through the lower extremity at the knee with the knee flexed versus at the foot with the knee extended or a direct blow injury. Therefore, a history of being a passenger or driver involved in a motor vehicle accident as opposed to being a pedestrian struck by a motor vehicle or having experienced a fall from a height can provide an expectation of the fracture type in addition to a tip-off to potential associated musculoskeletal injury. If awake and alert, the patient may complain of knee pain, being the first indication of an injury to the knee (patellar fractures, chondral injuries, and ligamentous injuries). Patients with a history of lower-energy trauma (sports-related injury, simple fall, etc.) in conjunction with hip pain require complete evaluation of the hip joint. An acetabular fracture resulting from a low-energy injury, such as a simple fall, is usually an isolated musculoskeletal injury in the underlying osteopenic bone. However, it is important to assess the reason for the fall. A critical underlying cardiac or neurologic medical condition may be the cause, especially in the elderly. 
Physical examination of any patient who has sustained a high-energy injury should follow standard ATLS protocol.3 In general, a complete examination of the musculoskeletal system is required, especially evaluation of the peripheral nerves. The initial examination of the patient should include evaluation of the lower extremity for any injury (soft tissue or otherwise). Local closed degloving soft tissue injuries about the hip (the Morel–Lavallé lesion) can harbor pathogenic bacteria and lead to wound breakdown and deep infection.62 Therefore, debridement followed by delayed wound closure and, subsequently, delayed fracture fixation may be required.62,93 More recently, a percutaneous method of debridement has been described.184 At the present time, the appropriate treatment method must be individualized and left to the judgment of the treating physician. Open wounds usually require debridement followed by delayed wound closure. Contusion to the knee is a red flag, indicating possible hip injury. 
A complete and clearly documented neurologic examination is extremely important both for patient prognosis and medicolegal concerns. Sciatic nerve injury is common in fractures with a posterior hip dislocation and fracture displacement of the posterior wall or column.93 It is often incomplete, most often involving the peroneal division.45,74,93,121 However, depending on the particular mechanism (i.e., stretch, impalement by fracture fragments, crush), injury can occur to smaller components of the nerve. Therefore, isolated sensory deficits and weakness or total loss of movement of individual muscles can occur. For example, it is possible on physical examination to have complete loss of tibialis anterior muscle function with the other muscles innervated by the sciatic nerve appearing to be intact. It is no wonder why these nerve injuries can be easily missed. Therefore, it is important to evaluate the patient’s ability to perform active ankle dorsiflexion in addition to toe dorsiflexion, along with ankle and toe plantar flexion. Obturator nerve function can be determined by assessing active firing of the hip adductors and femoral nerve function by eliciting active firing of the quadriceps femoris muscle. These examinations can usually be adequately performed in the acutely injured awake patient despite the presence of an acetabular fracture. Obviously, it is much better to diagnose at the time of injury than in the postoperative period, when the cause of the deficit could be attributed to an iatrogenic, rather than a traumatic, cause. 
Although physical examination of the injured limb is important, it may fail to identify a dislocation of the hip. Shortening of the entire limb should be present if the hip is dislocated. However, limb shortening of 1 or 2 cm is often hard to determine in this clinical setting. The physical findings regarding limb position commonly ascribed to a posterior dislocation of the hip (flexion, adduction, and internal rotation of the hip with a shortened lower extremity) may not be present.45,51 There are a few reasons for this situation. First, a dislocation may not be present at the time the patient presents to the hospital. Posterior wall fractures can occur with or without an associated frank dislocation of the hip joint, and a patient initially sustaining a posterior wall fracture-dislocation may have had the dislocation inadvertently reduced by the emergency personnel on the scene while being stabilized for transport to the hospital. Second, despite the existence of a posterior hip dislocation, the presence of a larger posterior wall fracture allows the femoral head to dislocate directly posterior without forcing the proximal femur into the expected abnormal position (Fig. 47-6). Therefore, a patient who presents with a flexed, adducted, and internally rotated hip often will have either a relatively small posterior wall fracture fragment or a pure posterior dislocation. Absence of this abnormal limb positioning does not preclude the presence of a posterior wall fracture and, in fact, may be associated with a large posterior wall fracture fragment.134 The treating physician must have a high level of suspicion of posterior wall fracture for any lower extremity injury that potentially causes abnormal loading to the hip joint. 
Figure 47-6
An anteroposterior radiograph (A) showing a dislocated hip on the right with the hip in neutral position.
 
Radiographic signs of a posterior hip dislocation include a break in Shenton line, proximal migration of the lesser trochanter, relatively smaller size of the affected femoral head (closer to the x-ray cassette), and a bony double density above the femoral head. The double density is the posterior wall fragment. It often sits atop the dislocated femoral head and can give the appearance of a normal joint space, potentially resulting in a misdiagnosis. Computed tomography (B) shows a large displaced posterior wall fracture with the femoral head essentially fallen posteriorly through the posterior wall deficit.
 
(Copyright Berton R. Moed, MD.)
Radiographic signs of a posterior hip dislocation include a break in Shenton line, proximal migration of the lesser trochanter, relatively smaller size of the affected femoral head (closer to the x-ray cassette), and a bony double density above the femoral head. The double density is the posterior wall fragment. It often sits atop the dislocated femoral head and can give the appearance of a normal joint space, potentially resulting in a misdiagnosis. Computed tomography (B) shows a large displaced posterior wall fracture with the femoral head essentially fallen posteriorly through the posterior wall deficit.
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Figure 47-6
An anteroposterior radiograph (A) showing a dislocated hip on the right with the hip in neutral position.
Radiographic signs of a posterior hip dislocation include a break in Shenton line, proximal migration of the lesser trochanter, relatively smaller size of the affected femoral head (closer to the x-ray cassette), and a bony double density above the femoral head. The double density is the posterior wall fragment. It often sits atop the dislocated femoral head and can give the appearance of a normal joint space, potentially resulting in a misdiagnosis. Computed tomography (B) shows a large displaced posterior wall fracture with the femoral head essentially fallen posteriorly through the posterior wall deficit.
(Copyright Berton R. Moed, MD.)
Radiographic signs of a posterior hip dislocation include a break in Shenton line, proximal migration of the lesser trochanter, relatively smaller size of the affected femoral head (closer to the x-ray cassette), and a bony double density above the femoral head. The double density is the posterior wall fragment. It often sits atop the dislocated femoral head and can give the appearance of a normal joint space, potentially resulting in a misdiagnosis. Computed tomography (B) shows a large displaced posterior wall fracture with the femoral head essentially fallen posteriorly through the posterior wall deficit.
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Imaging and Other Diagnostic Studies for Acetabular Fractures

The classification and subsequent treatment of acetabular fractures are based on imaging studies that have been derived from a thorough understanding of the anatomy of the innominate bone.78,93 The articular surface of the acetabulum can be visualized as being supported between the limbs of an inverted “Y” of a bone (Fig. 47-7). These columns are, in turn, connected to the sacroiliac articulation by a thick strut of bone lying above the greater sciatic notch, known as the sciatic buttress. Letournel was the first to describe the surgical anatomy of the innominate bone, identifying these two limbs as the anterior column or iliopectineal segment and posterior column or ilioischial segment.78,93 The anterior column refers to the anterior half of the iliac wing that is contiguous with the pelvic brim to the superior pubic ramus, as well as the anterior half of the acetabular articular surface. The posterior column begins at the superior aspect of the greater sciatic notch and is contiguous with the greater and lesser sciatic notches inferiorly and includes the ischial tuberosity. The anterior and posterior walls of the acetabulum are the components of the respective columns (Fig. 47-8). In addition, by recognizing that the plane of the ilium is approximately 90 degrees to the plane of the obturator foramen and that both of these structures are oriented roughly 45 degrees to the frontal plane, Judet et al. and Letournel and Judet78,93 determined that the AP pelvis and two 45-degree oblique views be used to study the radiographic anatomy of the acetabulum. Accurate interpretation of the plain radiographs results from correlation of the normal anatomy of the innominate bone with the pertinent radiographic landmarks seen on each view, and the current classification of acetabular fractures is directly derived from this original work of Letournel and Judet.78,93 Therefore, three radiographic projections of the pelvis are used to evaluate fractures of the acetabulum: The AP view of the pelvis, the obturator (or 45-degree internal, Judet) oblique view, and the iliac (or 45-degree external, Judet) oblique view.93 Interpretation of these plain films is based on the understanding of normal radiographic landmarks of the acetabulum and disruption of these landmarks represents a fracture involving that portion of the bone. These landmarks are referred to as “lines,” but they are not necessarily created by specific bony structures. Rather, they are generated by the tangency of the applied x-ray beam to a region of cortical bone. 
Figure 47-7
The acetabulum is supported by two columns in the shape on an inverted “Y.”
 
These are in turn linked to the sacrum by the sciatic buttress.
These are in turn linked to the sacrum by the sciatic buttress.
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Figure 47-7
The acetabulum is supported by two columns in the shape on an inverted “Y.”
These are in turn linked to the sacrum by the sciatic buttress.
These are in turn linked to the sacrum by the sciatic buttress.
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Figure 47-8
 
Columns of the innominate bone as described by Letournel and Judet,93 showing the ischiopubic ramus uniting the inferior ends of the anterior and posterior columns and highlighting the anterior and posterior wall articular surfaces. (Copyright Berton R. Moed, MD.)
Columns of the innominate bone as described by Letournel and Judet,93 showing the ischiopubic ramus uniting the inferior ends of the anterior and posterior columns and highlighting the anterior and posterior wall articular surfaces. (Copyright Berton R. Moed, MD.)
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Figure 47-8
Columns of the innominate bone as described by Letournel and Judet,93 showing the ischiopubic ramus uniting the inferior ends of the anterior and posterior columns and highlighting the anterior and posterior wall articular surfaces. (Copyright Berton R. Moed, MD.)
Columns of the innominate bone as described by Letournel and Judet,93 showing the ischiopubic ramus uniting the inferior ends of the anterior and posterior columns and highlighting the anterior and posterior wall articular surfaces. (Copyright Berton R. Moed, MD.)
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On the AP radiograph, there are six basic landmarks (Fig. 47-9A). These are the iliopectineal line, the ilioischial line, the radiographic U or teardrop, the roof of the acetabulum, the anterior rim of the acetabulum, and the posterior rim of the acetabulum.93 The iliopectineal line is the major landmark of the anterior column. The anterior three-quarters of the iliopectineal line represent the pelvic brim. The posterior quarter of this line is formed by the tangency of the x-ray beam to the internal cortical surface of the sciatic buttress and the internal part of the roof of the greater sciatic notch. The ilioischial line is formed by the tangency of the x-ray beam to the posterior portion of the quadrilateral surface (internal cortical surface of the acetabulum) and is considered a radiographic landmark of the posterior column. The radiographic U or teardrop consists of a medial and a lateral limb and represents a radiographic finding and not a true anatomic structure. The lateral limb represents the inferior aspect of the anterior wall in the acetabulum and the medial limb is formed by the obturator canal and the anteroinferior portion of the quadrilateral surface. Because the teardrop and the ilioischial line both result, in part, from the tangency of the x-ray beam to a portion of the quadrilateral surface, they are always superimposed on the AP pelvis view of the normal acetabulum.78,93 Dissociation of the teardrop and the ilioischial line indicates either rotation of the hemipelvis, or a fracture of the quadrilateral surface.106 The roof of the acetabulum is a radiographic landmark resulting from the tangency of the x-ray beam to a narrow portion of the subchondral bone of the superior acetabulum.93 Interruption of the radiographic line of the roof indicates a fracture involving the superior acetabulum. The anterior rim represents the lateral margin in the anterior wall of the acetabulum and is contiguous with the inferior margin of the superior pubic ramus.78 The anterior rim is typically medial to the posterior rim and has a characteristic undulation in its midcontour in the AP pelvis view. The posterior rim represents a lateral margin in the posterior wall of the acetabulum. Inferiorly, the posterior rim is contiguous with the thickened condensation of the posterior horn of the acetabulum and approximates a straight line, being more vertical than the anterior wall.93 
Figure 47-9
Radiographic lines of the acetabulum on different radiographic views.
 
A: Anteroposterior (AP) radiograph of the pelvis. 1, iliopectineal line; 2, ilioischial line; 3, teardrop; 4, acetabular roof; 5, anterior rim of the acetabulum; 6, posterior rim of the acetabulum. The iliopectineal line, the anterior rim, and teardrop are landmarks of the anterior column; the ilioischial line and posterior rim are landmarks of the posterior columns. B: Iliac oblique radiograph. 1, posterior border of the innominate bone; 2, anterior rim of the acetabulum, which is seen best on this view. The iliac wing is seen en face, and fracture lines extending into the iliac wing are often best seen on this view. The proper amount of rotation is indicated by the tip of the coccyx lying just above the center of the contralateral femoral head. C: Obturator oblique radiograph. 1, iliopectineal line; 2, posterior rim of the acetabulum. The obturator ring is seen en face, and posterior wall fractures are seen best on this view. The proper amount of rotation is indicated by the tip of the coccyx lying just above the center of the ipsilateral femoral head.
A: Anteroposterior (AP) radiograph of the pelvis. 1, iliopectineal line; 2, ilioischial line; 3, teardrop; 4, acetabular roof; 5, anterior rim of the acetabulum; 6, posterior rim of the acetabulum. The iliopectineal line, the anterior rim, and teardrop are landmarks of the anterior column; the ilioischial line and posterior rim are landmarks of the posterior columns. B: Iliac oblique radiograph. 1, posterior border of the innominate bone; 2, anterior rim of the acetabulum, which is seen best on this view. The iliac wing is seen en face, and fracture lines extending into the iliac wing are often best seen on this view. The proper amount of rotation is indicated by the tip of the coccyx lying just above the center of the contralateral femoral head. C: Obturator oblique radiograph. 1, iliopectineal line; 2, posterior rim of the acetabulum. The obturator ring is seen en face, and posterior wall fractures are seen best on this view. The proper amount of rotation is indicated by the tip of the coccyx lying just above the center of the ipsilateral femoral head.
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Figure 47-9
Radiographic lines of the acetabulum on different radiographic views.
A: Anteroposterior (AP) radiograph of the pelvis. 1, iliopectineal line; 2, ilioischial line; 3, teardrop; 4, acetabular roof; 5, anterior rim of the acetabulum; 6, posterior rim of the acetabulum. The iliopectineal line, the anterior rim, and teardrop are landmarks of the anterior column; the ilioischial line and posterior rim are landmarks of the posterior columns. B: Iliac oblique radiograph. 1, posterior border of the innominate bone; 2, anterior rim of the acetabulum, which is seen best on this view. The iliac wing is seen en face, and fracture lines extending into the iliac wing are often best seen on this view. The proper amount of rotation is indicated by the tip of the coccyx lying just above the center of the contralateral femoral head. C: Obturator oblique radiograph. 1, iliopectineal line; 2, posterior rim of the acetabulum. The obturator ring is seen en face, and posterior wall fractures are seen best on this view. The proper amount of rotation is indicated by the tip of the coccyx lying just above the center of the ipsilateral femoral head.
A: Anteroposterior (AP) radiograph of the pelvis. 1, iliopectineal line; 2, ilioischial line; 3, teardrop; 4, acetabular roof; 5, anterior rim of the acetabulum; 6, posterior rim of the acetabulum. The iliopectineal line, the anterior rim, and teardrop are landmarks of the anterior column; the ilioischial line and posterior rim are landmarks of the posterior columns. B: Iliac oblique radiograph. 1, posterior border of the innominate bone; 2, anterior rim of the acetabulum, which is seen best on this view. The iliac wing is seen en face, and fracture lines extending into the iliac wing are often best seen on this view. The proper amount of rotation is indicated by the tip of the coccyx lying just above the center of the contralateral femoral head. C: Obturator oblique radiograph. 1, iliopectineal line; 2, posterior rim of the acetabulum. The obturator ring is seen en face, and posterior wall fractures are seen best on this view. The proper amount of rotation is indicated by the tip of the coccyx lying just above the center of the ipsilateral femoral head.
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The iliac oblique view is taken with the patient rotated so that the injured hemipelvis is tilted 45 degrees away from the x-ray beam (Fig. 47-9B). This view shows the iliac wing in its largest dimension and profiles the greater and lesser sciatic notches, as well as the anterior rim of the acetabulum. Involvement of the posterior column is often best seen on this view.93,143 Fractures of the anterior column traversing the iliac wing can also be detected. 
The obturator oblique view is taken with the patient rotated so that the hemipelvis of interest is rotated 45 degrees toward the x-ray beam (Fig. 47-9C). This view shows the obturator foramen in its largest dimension and profiles the anterior column. The iliopectineal line has the same relationship with the pelvic brim as on the AP pelvis. The posterior rim of the acetabulum is best seen in the obturator oblique view. Comparison of the relationship of the femoral head with the posterior wall on the normal hip and the injured hip on the obturator oblique view will allow the surgeon to detect subtle amounts of posterior subluxation. A dislocated hip will become more obvious on the obturator oblique view (Fig. 47-10).22 
Figure 47-10
Anteroposterior (A) and obturator oblique view (B) showing a dislocated hip with an associated posterior wall fracture.
(Copyright Berton R. Moed, MD.)
(Copyright Berton R. Moed, MD.)
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A great deal of information can be acquired from the AP pelvis radiograph obtained in the emergency department as an adjunct to the primary survey and resuscitation phase of the ATLS protocol,3 including the initial diagnosis of the acetabular fracture and hip dislocation (Fig. 47-6A). The two 45-degree oblique views (Judet views) aid in classification of the fracture and to identify fracture displacements that may not be appreciable on the AP radiograph. These plain radiographs should be obtained with the patient out of traction; otherwise, there may be a false impression of hip joint congruity or an underestimation of fracture displacement. The Judet views are obtained by rolling the patient 45 degrees in relation to the x-ray beam. This may be difficult and painful for the patient and premedication is often required. To ensure that an appropriate oblique view is obtained, it is crucial that the pelvis is rotated the required amount (Fig. 47-9B, C). Although CT-derived, reconstructed radiographs have been offered as an alternative to this method of obtaining plain radiographs, further study is needed to validate their clinical utility (Fig. 47-11).17,141,174 Regardless of the method, an inadequately obtained radiograph may not demonstrate the radiograph landmarks needed to accurately determine the fracture pattern (Table 47-2). 
Figure 47-11
An obese 57-year-old man sustained multiple injuries, including an acetabular fracture, in a motor vehicle accident.
 
A: After a number of tries, this obturator oblique radiograph was considered acceptable. B: Obturator oblique radiograph generated from the computed tomography scan obtained on the day of injury. C: Selected three-dimensional computed tomography example in this patient.
 
(Copyright Berton R. Moed, MD.)
A: After a number of tries, this obturator oblique radiograph was considered acceptable. B: Obturator oblique radiograph generated from the computed tomography scan obtained on the day of injury. C: Selected three-dimensional computed tomography example in this patient.
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Figure 47-11
An obese 57-year-old man sustained multiple injuries, including an acetabular fracture, in a motor vehicle accident.
A: After a number of tries, this obturator oblique radiograph was considered acceptable. B: Obturator oblique radiograph generated from the computed tomography scan obtained on the day of injury. C: Selected three-dimensional computed tomography example in this patient.
(Copyright Berton R. Moed, MD.)
A: After a number of tries, this obturator oblique radiograph was considered acceptable. B: Obturator oblique radiograph generated from the computed tomography scan obtained on the day of injury. C: Selected three-dimensional computed tomography example in this patient.
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Table 47-2
Information Obtained from X-Ray Landmarks on Each Standard View
X-Ray View Information Regarding
Anteroposterior Pelvis
Iliopectineal line
Ilioischial line
Posterior lip
Anterior lip
Roof
Teardrop
Anterior column
Posterior column
Posterior column or wall
Anterior column or wall
Superior articular surface
Relationship of columns
Obturator Oblique
Pelvic brim
Posterior rim
Obturator ring
Roof
Anterior column
Posterior column or wall
Column involvement
Superior articular surface
Iliac Oblique
Greater and lesser sciatic notch
Quadrilateral surface of ischium
Anterior lip
Iliac wing
Roof
Posterior column (posterior border of innominate bone)
Posterior column (posterior border of innominate bone)
Anterior column or wall
Anterior column
Superior articular surface
X
The CT scan is an essential adjunct to the three radiographic projections to further define the fracture pattern and assess for associated bony injuries.93,141 However, it does not completely replace the standard radiographic evaluation.27,65,93,114,141 Therefore, two-dimensional (axial) and three-dimensional CT scans are used as an adjunct to the analysis of the AP and oblique plain radiographic projections.93,120,181 In order to obtain reliable and useful information, the CT scan should consist of contiguous sections of no more than 3-mm thickness. After studying the plain films (or perhaps their CT-reconstructed equivalents141), the surgeon should use CT to answer specific questions about the fracture that remain unanswered. Orientation of the fracture line(s) can be very helpful in distinguishing among fracture types (Fig. 47-12). In addition, two-dimensional axial images are superior to plain films in showing (a) the extent and location of acetabular wall fractures, (b) the presence of intra-articular free fragments or injury to the femoral head, (c) orientation of fracture lines, (d) identification of additional fracture lines (such as the vertical portion of the “T” type fracture and fractures of the quadrilateral plate), (e) rotation of fracture fragments, (f) the status of the posterior pelvic ring, and (g) marginal impaction, defined as depression of the articular surface of the joint (Fig. 47-13).93,181 In one study, the two-dimensional CT was shown to be superior to plain radiographs in the detection of fracture step and fracture gap deformities.18 However, displacements that occur in the plane of imaging may be underappreciated or averaged out. Although it has been shown that two-dimensional CT can accurately measure the size of posterior wall fracture fragments and subsequently advocated as a means to determine hip joint stability,28,84,185 it has proved unreliable in this regard.36,119,152 Furthermore, CT analysis may overestimate the extent of fracture comminution.93 When reviewing a two-dimensional CT study, it is important to evaluate the extent of the fracture fragments by following the fracture lines sequentially through the contiguous sections of the scan. In this way, errors of interpretation (such as mistaking the posterior inferior extent of a transverse fracture for a separate posterior wall fracture) can be avoided. 
Figure 47-12
Orientation of fracture lines on two-dimensional computed tomography as they relate to fracture morphology.
 
A: Fracture of one or both columns. B: Transverse fracture. C: Anterior wall. D: Posterior wall.
A: Fracture of one or both columns. B: Transverse fracture. C: Anterior wall. D: Posterior wall.
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Figure 47-12
Orientation of fracture lines on two-dimensional computed tomography as they relate to fracture morphology.
A: Fracture of one or both columns. B: Transverse fracture. C: Anterior wall. D: Posterior wall.
A: Fracture of one or both columns. B: Transverse fracture. C: Anterior wall. D: Posterior wall.
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Figure 47-13
Axial computed tomography section through the acetabulum.
 
The right acetabular posterior wall is fractured (black arrows). There is an intra-articular loose body between the femoral head and the acetabulum (white arrow). The asymmetry of the contour of the posterior wall from side to side is secondary to marginal impaction (white arrowhead), which occurs when a segment of the articular surface and the underlying cancellous bone adjacent to a major fracture line is impacted or depressed away from the normal contour of the joint.
 
(Copyright Berton R. Moed, MD.)
The right acetabular posterior wall is fractured (black arrows). There is an intra-articular loose body between the femoral head and the acetabulum (white arrow). The asymmetry of the contour of the posterior wall from side to side is secondary to marginal impaction (white arrowhead), which occurs when a segment of the articular surface and the underlying cancellous bone adjacent to a major fracture line is impacted or depressed away from the normal contour of the joint.
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Figure 47-13
Axial computed tomography section through the acetabulum.
The right acetabular posterior wall is fractured (black arrows). There is an intra-articular loose body between the femoral head and the acetabulum (white arrow). The asymmetry of the contour of the posterior wall from side to side is secondary to marginal impaction (white arrowhead), which occurs when a segment of the articular surface and the underlying cancellous bone adjacent to a major fracture line is impacted or depressed away from the normal contour of the joint.
(Copyright Berton R. Moed, MD.)
The right acetabular posterior wall is fractured (black arrows). There is an intra-articular loose body between the femoral head and the acetabulum (white arrow). The asymmetry of the contour of the posterior wall from side to side is secondary to marginal impaction (white arrowhead), which occurs when a segment of the articular surface and the underlying cancellous bone adjacent to a major fracture line is impacted or depressed away from the normal contour of the joint.
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Three-dimensional CT scan technology has improved to the point that it is very helpful in further defining the fracture pattern and, thereby, assisting in preoperative planning. However, it does not necessarily provide the diagnostic detail of the two-dimensional CT scan.141 The three-dimensional CT scan may also assist the surgeon who is inexperienced in interpreting the plain radiographs in developing a better understanding of the fracture patterns. The understanding of the fracture pattern is further enhanced by drawing the fracture lines from the radiograph landmarks onto a dry bone model or a line drawing of the pelvis as seen on each radiograph view. Only by understanding the location and orientation of each fracture line can the fracture pattern be truly appreciated. 
Dynamic stress views under general anesthesia have been used as a clinical measure of dynamic stability and congruence of the hip, and advocated as an adjunctive imaging study to assess the need for operative treatment in small and intermediate fractures of the posterior acetabular wall.36,119121,134,152,171,183,185 This stress examination is most applicable to fractures of the posterior wall.183 For this examination the patient is placed supine with the hip in neutral rotation and full extension. The hip is then gradually flexed past 90 degrees whereas progressive manual force is applied through the hip along the longitudinal axis of the femur. Simultaneously, fluoroscopic imaging of the hip in the AP and obturator oblique projections is performed.119,134,152 If the hip remains congruent on this assessment the examination is repeated with the addition of slight adduction and internal rotation (approximately 20 degrees).119,134,152 Frank redislocation is neither required nor clinically desirable. Posterior subluxation demonstrated in either view (indicted by a widening medial joint space or loss of joint parallelism) is indicative of dynamic hip instability (Fig. 47-14). 
Figure 47-14
Fluoroscopic views showing the dynamic examination of hip stability under anesthesia.
 
A: The intraoperative obturator oblique fluoroscopic view with the hip in full extension shows a located and congruent hip joint. B: The intraoperative obturator oblique fluoroscopic view with the hip in neutral rotation and flexed to approximately 90 degrees shows a located and a congruent hip joint. C: The intraoperative obturator oblique fluoroscopic view with the hip in neutral rotation and flexed to approximately 90 degrees with axial load applied shows gross subluxation with loss of hip joint parallelism and joint congruency (arrow) and gross enlargement of the medial clear space (arrowhead). (From Moed BR, Ajibade DA, Israel H. Computed tomography as a predictor of hip stability status in posterior wall fractures of the acetabulum. J Orthop Trauma. 2009;23:7–15.)
A: The intraoperative obturator oblique fluoroscopic view with the hip in full extension shows a located and congruent hip joint. B: The intraoperative obturator oblique fluoroscopic view with the hip in neutral rotation and flexed to approximately 90 degrees shows a located and a congruent hip joint. C: The intraoperative obturator oblique fluoroscopic view with the hip in neutral rotation and flexed to approximately 90 degrees with axial load applied shows gross subluxation with loss of hip joint parallelism and joint congruency (arrow) and gross enlargement of the medial clear space (arrowhead). (From Moed BR, Ajibade DA, Israel H. Computed tomography as a predictor of hip stability status in posterior wall fractures of the acetabulum. J Orthop Trauma. 2009;23:7–15.)
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Figure 47-14
Fluoroscopic views showing the dynamic examination of hip stability under anesthesia.
A: The intraoperative obturator oblique fluoroscopic view with the hip in full extension shows a located and congruent hip joint. B: The intraoperative obturator oblique fluoroscopic view with the hip in neutral rotation and flexed to approximately 90 degrees shows a located and a congruent hip joint. C: The intraoperative obturator oblique fluoroscopic view with the hip in neutral rotation and flexed to approximately 90 degrees with axial load applied shows gross subluxation with loss of hip joint parallelism and joint congruency (arrow) and gross enlargement of the medial clear space (arrowhead). (From Moed BR, Ajibade DA, Israel H. Computed tomography as a predictor of hip stability status in posterior wall fractures of the acetabulum. J Orthop Trauma. 2009;23:7–15.)
A: The intraoperative obturator oblique fluoroscopic view with the hip in full extension shows a located and congruent hip joint. B: The intraoperative obturator oblique fluoroscopic view with the hip in neutral rotation and flexed to approximately 90 degrees shows a located and a congruent hip joint. C: The intraoperative obturator oblique fluoroscopic view with the hip in neutral rotation and flexed to approximately 90 degrees with axial load applied shows gross subluxation with loss of hip joint parallelism and joint congruency (arrow) and gross enlargement of the medial clear space (arrowhead). (From Moed BR, Ajibade DA, Israel H. Computed tomography as a predictor of hip stability status in posterior wall fractures of the acetabulum. J Orthop Trauma. 2009;23:7–15.)
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Classification of Acetabular Fractures

Judet et al. proposed the first systematic classification of acetabular fractures initially published as a thesis by Letournel in 1961.95 This classification is based on the anatomic pattern of the fracture. It was derived by first understanding the radiograph landmarks on the intact dry innominate and then analyzing these landmarks in fracture cases.78 
Over time this classification was modified and improved by Letournel.94 The comprehensive fracture classification systems of the Orthopaedic Trauma Association103 and the AO70 describe the alphanumeric coding of the classification devised by Judet et al. and finalized by Letournel78,93,94 and offer no clinical advantage. Therefore the “Letournel” acetabular fracture classification continues to remain the international language of the majority of surgeons treating these complex injuries. 
This classification has 10 distinct categories which are divided into five elementary types and five associated types (Fig. 47-15). The five elementary fracture patterns are the anterior wall, anterior column, posterior wall, posterior column, and transverse (Table 47-3). The elementary fracture patterns are defined as those fractures that separate all or part of a single column of the acetabulum. The anterior and posterior column fractures separate the entire column from the intact innominate; whereas the anterior and posterior wall fractures separate only that portion of the column’s articular surface. The transverse fracture pattern consists of a single fracture line that traverses both the anterior and posterior columns of the acetabulum. This fracture is included as elementary because of the fundamental nature of the fracture pattern. The associated patterns are either a combination of elementary patterns or an elementary pattern with an additional fracture component. The five associated fracture patterns are the posterior column and posterior wall, anterior column or wall and posterior hemitransverse, transverse and posterior wall, T-shaped, and both-column fracture (see Table 47-3). 
Figure 47-15
Letournel acetabular fracture classification.
 
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868, with permission.)
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868, with permission.)
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Figure 47-15
Letournel acetabular fracture classification.
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868, with permission.)
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868, with permission.)
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Table 47-3
Letournel Classification of Acetabular Fractures
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Table 47-3
Letournel Classification of Acetabular Fractures
Elementary Fracture Patterns
  •  
    Posterior wall
  •  
    Posterior column
  •  
    Anterior wall
  •  
    Anterior column
  •  
    Transverse
Associated Fracture Patterns
  •  
    Posterior column and posterior wall
  •  
    Transverse and posterior wall
  •  
    Anterior column (or wall) and posterior hemitransverse
  •  
    T-shaped
  •  
    Both-column
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Variants of these 10 basic types are not uncommon, which is a situation that was well recognized and described by Letournel and Judet.94 However, these variants can usually be easily integrated into the system. This system is important not only for its ability to describe the fracture, but also it serves as a guide for subsequent operative treatment. High rates of interobserver and intraobserver reliability have been reported using this classification system based purely on interpretation of the three standard plain radiographs of the pelvis as well as using CT-derived imaging.12,141 

Elementary Fracture Types of the Acetabulum

Posterior Wall Acetabular Fractures.
Fractures of the posterior wall of the acetabulum are the most common type of acetabular fracture accounting for approximately 25% of all acetabular fractures.93,107,121 The simple appearance of the posterior wall fracture on plain radiographs underestimates its potential complexity. Rather than having one simple fracture fragment most posterior wall fractures are comminuted or have areas where the articular surface along the margin of the primary fracture line is impacted into the underlying cancellous bone. Fractures of the posterior wall can be visualized on the AP and obturator oblique radiographs with the obturator oblique providing the best radiograph view (Fig. 47-16). The AP pelvis radiograph will generally reveal a disruption only in the posterior rim shadow. If the wall fragment is large enough and superior in location the roof shadow may also be disrupted. The obturator oblique radiograph will demonstrate the size and multifragmentary nature of the fracture. The iliac oblique view will reveal that the posterior border of the innominate bone, the anterior border of the acetabulum, and the iliac wing are uninvolved. CT scans are particularly helpful in identifying fracture comminution and marginal impaction (Fig. 47-13). Marginal impaction is a rotated and impacted osteochondral fragment that is displaced as the femoral head dislocates and the wall fractures (Fig. 47-17). This may occur with any fracture pattern but has been documented in up to 46% of posterior wall fractures.121 
Figure 47-16
Radiographs of a posterior wall fracture.
 
A: Anteroposterior view shows all radiographic landmarks to be intact except the posterior rim (arrow). B: The obturator oblique view shows the displaced posterior wall fracture (arrow). C: The iliac oblique view shows an intact posterior border. B C
 
(Copyright Berton R. Moed, MD.)
A: Anteroposterior view shows all radiographic landmarks to be intact except the posterior rim (arrow). B: The obturator oblique view shows the displaced posterior wall fracture (arrow). C: The iliac oblique view shows an intact posterior border. B C
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Figure 47-16
Radiographs of a posterior wall fracture.
A: Anteroposterior view shows all radiographic landmarks to be intact except the posterior rim (arrow). B: The obturator oblique view shows the displaced posterior wall fracture (arrow). C: The iliac oblique view shows an intact posterior border. B C
(Copyright Berton R. Moed, MD.)
A: Anteroposterior view shows all radiographic landmarks to be intact except the posterior rim (arrow). B: The obturator oblique view shows the displaced posterior wall fracture (arrow). C: The iliac oblique view shows an intact posterior border. B C
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Figure 47-17
 
Intraoperative photograph shows the femoral head (asterisk), the remaining intact articular surface (white arrow), and a large marginally impacted fragment (white arrowhead). (From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90[suppl 1]:87–107. Permission granted.)
Intraoperative photograph shows the femoral head (asterisk), the remaining intact articular surface (white arrow), and a large marginally impacted fragment (white arrowhead). (From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90[suppl 1]:87–107. Permission granted.)
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Figure 47-17
Intraoperative photograph shows the femoral head (asterisk), the remaining intact articular surface (white arrow), and a large marginally impacted fragment (white arrowhead). (From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90[suppl 1]:87–107. Permission granted.)
Intraoperative photograph shows the femoral head (asterisk), the remaining intact articular surface (white arrow), and a large marginally impacted fragment (white arrowhead). (From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90[suppl 1]:87–107. Permission granted.)
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Posterior Column Acetabular Fractures.
Fractures of the posterior column involve detachment of the entire ischioacetabular segment from the innominate bone and represent 3% to 5% of acetabular fractures.93,107,112 The fracture begins at the posterior border of the innominate bone near the apex of the greater sciatic notch. It descends across the articular surface, quadrilateral surface, ischiopubic notch (roof of the obturator canal), and finally across the inferior ramus. On the AP radiograph the ilioischial line, the posterior rim, and the inferior ramus are disrupted. The disruption of the posterior rim will be seen in only one location where the fracture line crosses the rim. This is in distinction to the posterior wall fracture where the posterior rim will be seen to be disrupted in two locations separating a portion of the articular surface. The iliac oblique radiograph demonstrates the fracture crossing the posterior border of the bone. The fracture of the ischiopubic ramus and posterior rim are confirmed on the obturator oblique. The iliopectineal line is preserved on all views. The femoral head follows the displacement of the posterior column posteriorly and medially (Fig. 47-18). The ilioischial line is typically displaced relative to the radiographic U (Fig. 47-18A). However, when a large portion of the quadrilateral surface remains intact with the posterior column the radiographic U will displace with the ilioischial line.93 Fractures of the posterior column are notoriously unstable and skeletal traction is frequently required to keep the femoral head reduced beneath the intact portion of the roof. The posterior column fracture frequently involves the greater sciatic notch at or above the location of the superior gluteal neurovascular bundle. In widely displaced fractures it is common to find the neurovascular bundle in the posterior column fracture site and it must be carefully extracted before reduction of the fracture to prevent iatrogenic injury. 
Figure 47-18
Radiographic appearance of the posterior column fracture.
 
A: On the anteroposterior view, the displacement of the ilioischial line (arrow) is apparent whereas the iliopectineal line is seen to be intact (black arrowheads). As typical, the ilioischial line (arrow) is displaced relative to the radiographic U (white arrowhead). B: The obturator oblique view confirms the anterior column to be intact (arrowheads) and demonstrates the fracture of the ischial ramus (arrow). C: The iliac oblique view shows the disruption of the greater sciatic notch and the displacement of the posterior column (arrow). D: The computed tomography section shows a fracture line typical of a posterior column fracture.
 
(Copyright Berton R. Moed, MD.)
A: On the anteroposterior view, the displacement of the ilioischial line (arrow) is apparent whereas the iliopectineal line is seen to be intact (black arrowheads). As typical, the ilioischial line (arrow) is displaced relative to the radiographic U (white arrowhead). B: The obturator oblique view confirms the anterior column to be intact (arrowheads) and demonstrates the fracture of the ischial ramus (arrow). C: The iliac oblique view shows the disruption of the greater sciatic notch and the displacement of the posterior column (arrow). D: The computed tomography section shows a fracture line typical of a posterior column fracture.
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Figure 47-18
Radiographic appearance of the posterior column fracture.
A: On the anteroposterior view, the displacement of the ilioischial line (arrow) is apparent whereas the iliopectineal line is seen to be intact (black arrowheads). As typical, the ilioischial line (arrow) is displaced relative to the radiographic U (white arrowhead). B: The obturator oblique view confirms the anterior column to be intact (arrowheads) and demonstrates the fracture of the ischial ramus (arrow). C: The iliac oblique view shows the disruption of the greater sciatic notch and the displacement of the posterior column (arrow). D: The computed tomography section shows a fracture line typical of a posterior column fracture.
(Copyright Berton R. Moed, MD.)
A: On the anteroposterior view, the displacement of the ilioischial line (arrow) is apparent whereas the iliopectineal line is seen to be intact (black arrowheads). As typical, the ilioischial line (arrow) is displaced relative to the radiographic U (white arrowhead). B: The obturator oblique view confirms the anterior column to be intact (arrowheads) and demonstrates the fracture of the ischial ramus (arrow). C: The iliac oblique view shows the disruption of the greater sciatic notch and the displacement of the posterior column (arrow). D: The computed tomography section shows a fracture line typical of a posterior column fracture.
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Anterior Wall Acetabular Fractures.
The anterior wall fracture begins below the anterior inferior iliac spine, crosses the articular surface to the pelvic brim, and proceeds down the quadrilateral surface to the ischiopubic notch. A secondary fracture line through the superior ramus detaches the anterior wall portion. Anterior wall fractures are rare, and constitute only 1% to 2% of all fractures.93,107,112 The anterior rim shadow and the iliopectineal line on the AP radiograph will show displacement in two locations, but all posterior landmarks will remain intact. A portion of the quadrilateral surface may be detached with the anterior wall and this may result in an apparent “thinning” or reduplication of the ilioischial line, but some portion of the line will remain intact. Femoral head subluxation is commonly seen and the head will be noted to follow the anterior wall fragment, particularly visible on the obturator oblique radiograph (Fig. 47-19). 
Figure 47-19
Radiographic appearance of the anterior wall fracture, as described by Letournel and Judet.93
 
A: On the anteroposterior (AP) view, the disruption of the iliopectineal line is seen in two locations. B: The obturator oblique confirms this and demonstrates that the femoral head remains congruent to the anterior wall segment. C: The iliac oblique view confirms the posterior border of the bone to be intact and that the ilioischial line disruption seen on the AP view is because of a fragment of quadrilateral surface comminution and does not represent a fracture through the posterior border of the innominate bone. This explains the normal position of the ischium despite the ilioischial line displacement.
 
(Courtesy of Michael Stover, MD.)
A: On the anteroposterior (AP) view, the disruption of the iliopectineal line is seen in two locations. B: The obturator oblique confirms this and demonstrates that the femoral head remains congruent to the anterior wall segment. C: The iliac oblique view confirms the posterior border of the bone to be intact and that the ilioischial line disruption seen on the AP view is because of a fragment of quadrilateral surface comminution and does not represent a fracture through the posterior border of the innominate bone. This explains the normal position of the ischium despite the ilioischial line displacement.
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Figure 47-19
Radiographic appearance of the anterior wall fracture, as described by Letournel and Judet.93
A: On the anteroposterior (AP) view, the disruption of the iliopectineal line is seen in two locations. B: The obturator oblique confirms this and demonstrates that the femoral head remains congruent to the anterior wall segment. C: The iliac oblique view confirms the posterior border of the bone to be intact and that the ilioischial line disruption seen on the AP view is because of a fragment of quadrilateral surface comminution and does not represent a fracture through the posterior border of the innominate bone. This explains the normal position of the ischium despite the ilioischial line displacement.
(Courtesy of Michael Stover, MD.)
A: On the anteroposterior (AP) view, the disruption of the iliopectineal line is seen in two locations. B: The obturator oblique confirms this and demonstrates that the femoral head remains congruent to the anterior wall segment. C: The iliac oblique view confirms the posterior border of the bone to be intact and that the ilioischial line disruption seen on the AP view is because of a fragment of quadrilateral surface comminution and does not represent a fracture through the posterior border of the innominate bone. This explains the normal position of the ischium despite the ilioischial line displacement.
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As has been stated, there are many variants of the 10 basic fracture types, which can usually be easily integrated into the system. In the morphologic description of the anterior wall fracture, as detailed above, a segment of the inner table of the pelvis (the pelvic brim) is included with the anterior rim fragment (Fig. 47-15). A different fracture pattern involving the anterior acetabular rim, which does not include the inner table, has been categorized as the “anterior wall” fracture type by the AO in their classification system.70 In addition, the 1993 publication of Letournel and Judet93 reveals no similarly described fracture. No classification system can be expected to describe every possible variant and exceptions are the norm. However, it is quite apparent that there is some uncertainty in the literature regarding the anterior wall fracture, possibly contributing to confused diagnoses and treatment recommendations. This isolated anterior wall fracture, which does not involve the pelvic brim, is the morphologic analogue to the posterior wall fracture (Fig. 47-20). This variant is rare, constituting approximately 1.5% of acetabular fractures in one series.92 
Figure 47-20
Drawing showing the anterior wall fracture variant drawn on the intra-articular surface of the acetabulum.
(Copyright Berton R. Moed, MD.)
(Copyright Berton R. Moed, MD.)
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Anterior Column Acetabular Fractures.
Anterior column fractures make up 3% to 5% of all acetabulum fractures.93,107,112 Anterior column fractures separate the anterior border of the innominate bone from the intact ilium. The type of anterior column fracture is named by the location where the fracture exits the anterior aspect of the bone. High anterior column fractures exit the iliac crest, intermediate fractures exit the anterior superior iliac spine, low fractures exit the psoas gutter just below the anterior inferior iliac spine, and very low anterior column fractures exit the bone at the iliopectineal eminence (Fig. 47-21). All anterior column fractures, regardless of where they exit the bone superiorly, cross the pelvic brim, proceed down the quadrilateral surface, and enter the ischiopubic notch, ultimately ending in a fracture of the inferior ramus. Typically, the lower the fracture crosses the anterior border of the bone, the more inferior is the site of fracture of the ischiopubic ramus. As in the anterior wall fractures, it is common for a portion of the quadrilateral surface to be detached as a separate fragment but the posterior border of the innominate bone remains intact. The iliopectineal line is disrupted in one location on the obturator oblique and AP views. The very low anterior column fracture can be distinguished from the typical anterior wall fracture in that it has a fracture of the inferior pubic ramus and a single break in the iliopectineal line. The femoral head displaces with the anterior column fracture. The typical displacement is an external rotation of the anterior fragment about the femoral head allowing the head to move medially and superiorly (Fig. 47-22). 
Figure 47-21
The various subgroups of the anterior column fracture: (A) very low, (B) low, (C) intermediate, and (D) high.
 
(After Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993.)
(After Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993.)
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Figure 47-21
The various subgroups of the anterior column fracture: (A) very low, (B) low, (C) intermediate, and (D) high.
(After Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993.)
(After Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag; 1993.)
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Figure 47-22
Radiographic appearance of the anterior column fracture.
 
A: The AP view demonstrates the fracture from the iliac crest to the hip joint with disruption of the roof. A small area of comminution at the pelvic brim is noted. The ischial ramus fracture is also noted. B: The obturator oblique demonstrates a single break in the iliopectineal line where the anterior column fracture crosses the pelvic brim. Although difficult to see, the disruption of the ilium can be appreciated as a reduplication of the cortical lines of the internal iliac and fossa and external wing of the ilium. C: The iliac oblique view confirms the posterior border of the bone to be intact.
A: The AP view demonstrates the fracture from the iliac crest to the hip joint with disruption of the roof. A small area of comminution at the pelvic brim is noted. The ischial ramus fracture is also noted. B: The obturator oblique demonstrates a single break in the iliopectineal line where the anterior column fracture crosses the pelvic brim. Although difficult to see, the disruption of the ilium can be appreciated as a reduplication of the cortical lines of the internal iliac and fossa and external wing of the ilium. C: The iliac oblique view confirms the posterior border of the bone to be intact.
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Figure 47-22
Radiographic appearance of the anterior column fracture.
A: The AP view demonstrates the fracture from the iliac crest to the hip joint with disruption of the roof. A small area of comminution at the pelvic brim is noted. The ischial ramus fracture is also noted. B: The obturator oblique demonstrates a single break in the iliopectineal line where the anterior column fracture crosses the pelvic brim. Although difficult to see, the disruption of the ilium can be appreciated as a reduplication of the cortical lines of the internal iliac and fossa and external wing of the ilium. C: The iliac oblique view confirms the posterior border of the bone to be intact.
A: The AP view demonstrates the fracture from the iliac crest to the hip joint with disruption of the roof. A small area of comminution at the pelvic brim is noted. The ischial ramus fracture is also noted. B: The obturator oblique demonstrates a single break in the iliopectineal line where the anterior column fracture crosses the pelvic brim. Although difficult to see, the disruption of the ilium can be appreciated as a reduplication of the cortical lines of the internal iliac and fossa and external wing of the ilium. C: The iliac oblique view confirms the posterior border of the bone to be intact.
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Transverse Acetabular Fractures.
Transverse fractures comprise 5% to 19% of acetabular fractures.93,107,112 They are the only elementary fracture pattern that breaks both the anterior and posterior border of the innominate bone. The fracture separates the innominate bone into two pieces: The upper iliac piece and the lower ischiopubic segment. The upper fragment is intact to the ilium whereas the ischiopubic fragment rotates about the symphysis pubis. This results in a medial and superior displacement of the head, as it follows the ischiopubic segment. This rotation also typically produces a greater translational displacement of the transverse fracture at the posterior border rather than the anterior border of the bone. Transverse fractures are subdivided by where the fracture crosses the articular surface. Transtectal fractures cross the weight-bearing dome of the acetabulum. Juxtatectal fractures cross the articular surface at the level of the top of the cotyloid fossa. Infratectal fractures cross the cotyloid fossa (Fig. 47-23). As the location of the fracture moves more superior on the articular surface, the orientation of the fracture also becomes more vertical and the size of the intact remaining articular surface decreases. This has definite implications for the surgical treatment of these injuries. The AP radiograph demonstrates a disruption of both the ilioischial and iliopectineal lines as well as the anterior and posterior rim shadows. In transtectal fractures, the roof line will be disrupted as well. However, the ilioischial line maintains its normal relationship with the radiographic as there is no fracture at this level. The oblique views will show disruption of the pelvic brim as well as the posterior border of the bone. The ischial ramus will not be fractured. On CT scan, the fracture line is oriented in an AP direction in the axial section (Fig. 47-24). 
Figure 47-23
The various subgroups of the transverse fracture.
 
Infratectal type (A), juxtatectal type (B), and transtectal type (C).
 
(Redrawn after Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. New York, NY: Springer-Verlag; 1993.)
Infratectal type (A), juxtatectal type (B), and transtectal type (C).
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Figure 47-23
The various subgroups of the transverse fracture.
Infratectal type (A), juxtatectal type (B), and transtectal type (C).
(Redrawn after Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. New York, NY: Springer-Verlag; 1993.)
Infratectal type (A), juxtatectal type (B), and transtectal type (C).
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Figure 47-24
Radiographic appearance of the transverse fracture.
 
A: The anteroposterior pelvis view demonstrates disruption of four of the six radiograph landmarks of the acetabulum with the ilioischial line maintaining its normal relationship with the radiographic U (arrow), indicating that this is a transverse fracture below the level of the roof. Note the subluxation of the femoral head away from the intact portion of the acetabular roof. B: The obturator oblique view shows a break in the iliopectineal line (arrow) and subluxation of the femoral head with the displacement of the ischiopubic segment and verifies that the ischial ramus is not broken. C: The iliac oblique shows where the transverse fracture exits the greater sciatic notch (arrow) and again confirms the subluxation of the femoral head. D: This computed tomography section shows the orientation typical of a transverse fracture.
 
(Copyright Berton R. Moed, MD.)
A: The anteroposterior pelvis view demonstrates disruption of four of the six radiograph landmarks of the acetabulum with the ilioischial line maintaining its normal relationship with the radiographic U (arrow), indicating that this is a transverse fracture below the level of the roof. Note the subluxation of the femoral head away from the intact portion of the acetabular roof. B: The obturator oblique view shows a break in the iliopectineal line (arrow) and subluxation of the femoral head with the displacement of the ischiopubic segment and verifies that the ischial ramus is not broken. C: The iliac oblique shows where the transverse fracture exits the greater sciatic notch (arrow) and again confirms the subluxation of the femoral head. D: This computed tomography section shows the orientation typical of a transverse fracture.
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Figure 47-24
Radiographic appearance of the transverse fracture.
A: The anteroposterior pelvis view demonstrates disruption of four of the six radiograph landmarks of the acetabulum with the ilioischial line maintaining its normal relationship with the radiographic U (arrow), indicating that this is a transverse fracture below the level of the roof. Note the subluxation of the femoral head away from the intact portion of the acetabular roof. B: The obturator oblique view shows a break in the iliopectineal line (arrow) and subluxation of the femoral head with the displacement of the ischiopubic segment and verifies that the ischial ramus is not broken. C: The iliac oblique shows where the transverse fracture exits the greater sciatic notch (arrow) and again confirms the subluxation of the femoral head. D: This computed tomography section shows the orientation typical of a transverse fracture.
(Copyright Berton R. Moed, MD.)
A: The anteroposterior pelvis view demonstrates disruption of four of the six radiograph landmarks of the acetabulum with the ilioischial line maintaining its normal relationship with the radiographic U (arrow), indicating that this is a transverse fracture below the level of the roof. Note the subluxation of the femoral head away from the intact portion of the acetabular roof. B: The obturator oblique view shows a break in the iliopectineal line (arrow) and subluxation of the femoral head with the displacement of the ischiopubic segment and verifies that the ischial ramus is not broken. C: The iliac oblique shows where the transverse fracture exits the greater sciatic notch (arrow) and again confirms the subluxation of the femoral head. D: This computed tomography section shows the orientation typical of a transverse fracture.
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Associated Fracture Types of the Acetabulum

Posterior Column and Posterior Wall Acetabular Fractures.
The posterior column and posterior wall fracture is a combination of the two elementary fracture patterns, posterior column and posterior wall, and makes up 3% to 4% of fractures.93,107,112 The posterior column fracture divides the posterior border of the innominate bone and the ischium to produce a free ischioacetabular fragment. The posterior wall component can be thought of as articular comminution of the posterior rim where the posterior column fracture traverses it. The femoral head is frequently dislocated on presentation, with the femoral head following the ischioacetabular fragment and dislocating cranially and posteriorly. The posterior wall fragment remains with the femoral head while dislocated but typically stays in a displaced position once the femoral head is reduced. The posterior wall fracture may block reduction of the hip by interposition between the head and the posterior column or by incarcerating within the joint. Radiographically, the disrupted landmarks, as expected, are the ilioischial line, posterior border of the innominate bone, and the posterior rim. The radiograph roof may also be displaced depending on how superior the posterior wall component extends. The displacement of the posterior column may be difficult to assess on the AP radiograph as posterior displacement of the column may result in the ilioischial line maintaining an almost normal relationship to the radiograph teardrop (Fig. 47-25). 
Figure 47-25
Radiographic appearance of the associated posterior column and posterior wall fracture.
 
A: The anteroposterior pelvis radiograph shows the disruption of the ilioischial (black arrow) but not the iliopectineal lines (black arrowheads), and the ischial ramus fracture is present (white arrowhead), and the posterior wall fragment can be appreciated overlying the roof of the acetabulum (white arrow). B: The obturator oblique view shows the displaced posterior wall fragment (white arrow), the ischial ramus fracture (white arrowhead), and the intact iliopectineal line (black arrowhead). C: The iliac oblique demonstrates the disruption of the greater sciatic notch and the posterior wall fragment superimposed on the roof of the acetabulum (black arrow). D: This computed tomography section shows the posterior wall fracture (arrow) with a column fracture line typical of a posterior column fracture (black arrowheads).
 
(Copyright Berton R. Moed, MD.)
A: The anteroposterior pelvis radiograph shows the disruption of the ilioischial (black arrow) but not the iliopectineal lines (black arrowheads), and the ischial ramus fracture is present (white arrowhead), and the posterior wall fragment can be appreciated overlying the roof of the acetabulum (white arrow). B: The obturator oblique view shows the displaced posterior wall fragment (white arrow), the ischial ramus fracture (white arrowhead), and the intact iliopectineal line (black arrowhead). C: The iliac oblique demonstrates the disruption of the greater sciatic notch and the posterior wall fragment superimposed on the roof of the acetabulum (black arrow). D: This computed tomography section shows the posterior wall fracture (arrow) with a column fracture line typical of a posterior column fracture (black arrowheads).
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Figure 47-25
Radiographic appearance of the associated posterior column and posterior wall fracture.
A: The anteroposterior pelvis radiograph shows the disruption of the ilioischial (black arrow) but not the iliopectineal lines (black arrowheads), and the ischial ramus fracture is present (white arrowhead), and the posterior wall fragment can be appreciated overlying the roof of the acetabulum (white arrow). B: The obturator oblique view shows the displaced posterior wall fragment (white arrow), the ischial ramus fracture (white arrowhead), and the intact iliopectineal line (black arrowhead). C: The iliac oblique demonstrates the disruption of the greater sciatic notch and the posterior wall fragment superimposed on the roof of the acetabulum (black arrow). D: This computed tomography section shows the posterior wall fracture (arrow) with a column fracture line typical of a posterior column fracture (black arrowheads).
(Copyright Berton R. Moed, MD.)
A: The anteroposterior pelvis radiograph shows the disruption of the ilioischial (black arrow) but not the iliopectineal lines (black arrowheads), and the ischial ramus fracture is present (white arrowhead), and the posterior wall fragment can be appreciated overlying the roof of the acetabulum (white arrow). B: The obturator oblique view shows the displaced posterior wall fragment (white arrow), the ischial ramus fracture (white arrowhead), and the intact iliopectineal line (black arrowhead). C: The iliac oblique demonstrates the disruption of the greater sciatic notch and the posterior wall fragment superimposed on the roof of the acetabulum (black arrow). D: This computed tomography section shows the posterior wall fracture (arrow) with a column fracture line typical of a posterior column fracture (black arrowheads).
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Transverse and Posterior Wall Acetabular Fractures.
The transverse and posterior wall fracture combines the elementary transverse and posterior wall fracture patterns and makes up approximately 20% of all fractures.93,107,112 As with the elementary patterns, the transverse component may be transtectal, juxtatectal, or infratectal, and the posterior wall component may be single or multifragmentary and associated with marginal impaction. Dislocation of the femoral head is common in these fractures and the dislocation may be either posteriorly through the wall defect or medially through the transverse fracture. Distinction between the two is important because an early recognition of a posterior dislocation is necessary to minimize such complications as osteonecrosis, sciatic nerve injury, and femoral head damage. When the posterior wall fragment is minimally displaced, it may be missed on the AP pelvis radiograph, but it is commonly seen on the obturator oblique view, as well as with axial CT (Fig. 47-26). 
Figure 47-26
Radiographic appearance of the associated transverse and posterior wall fracture (transtectal pattern).
 
A: The appearance on the anteroposterior radiograph is quite similar to that of the pure transverse fracture with disruption of five of the six radiograph landmarks; only the radiographic U (which maintains its normal relationship to the ilioischial line) remains intact. The posterior wall fragment is seen as an oblique cortical line overlying the intact roof (arrowhead). B: The obturator oblique shows the transverse fracture, the subluxation of the femoral head with the ischiopubic fragment, as well as the posterior wall fragment. It is easy to see on this view how the femoral head may abrade against the fracture edge whereas the hip is subluxated. C: The iliac oblique view highlights the fracture line exiting the greater sciatic notch as well as the posterior wall fragment superimposed on the roof of the acetabulum (black arrow). D: This computed tomography section shows the posterior wall fracture (white arrow) with a column fracture line typical of a transverse fracture (black arrowheads).
 
(Copyright Berton R. Moed, MD.)
A: The appearance on the anteroposterior radiograph is quite similar to that of the pure transverse fracture with disruption of five of the six radiograph landmarks; only the radiographic U (which maintains its normal relationship to the ilioischial line) remains intact. The posterior wall fragment is seen as an oblique cortical line overlying the intact roof (arrowhead). B: The obturator oblique shows the transverse fracture, the subluxation of the femoral head with the ischiopubic fragment, as well as the posterior wall fragment. It is easy to see on this view how the femoral head may abrade against the fracture edge whereas the hip is subluxated. C: The iliac oblique view highlights the fracture line exiting the greater sciatic notch as well as the posterior wall fragment superimposed on the roof of the acetabulum (black arrow). D: This computed tomography section shows the posterior wall fracture (white arrow) with a column fracture line typical of a transverse fracture (black arrowheads).
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Figure 47-26
Radiographic appearance of the associated transverse and posterior wall fracture (transtectal pattern).
A: The appearance on the anteroposterior radiograph is quite similar to that of the pure transverse fracture with disruption of five of the six radiograph landmarks; only the radiographic U (which maintains its normal relationship to the ilioischial line) remains intact. The posterior wall fragment is seen as an oblique cortical line overlying the intact roof (arrowhead). B: The obturator oblique shows the transverse fracture, the subluxation of the femoral head with the ischiopubic fragment, as well as the posterior wall fragment. It is easy to see on this view how the femoral head may abrade against the fracture edge whereas the hip is subluxated. C: The iliac oblique view highlights the fracture line exiting the greater sciatic notch as well as the posterior wall fragment superimposed on the roof of the acetabulum (black arrow). D: This computed tomography section shows the posterior wall fracture (white arrow) with a column fracture line typical of a transverse fracture (black arrowheads).
(Copyright Berton R. Moed, MD.)
A: The appearance on the anteroposterior radiograph is quite similar to that of the pure transverse fracture with disruption of five of the six radiograph landmarks; only the radiographic U (which maintains its normal relationship to the ilioischial line) remains intact. The posterior wall fragment is seen as an oblique cortical line overlying the intact roof (arrowhead). B: The obturator oblique shows the transverse fracture, the subluxation of the femoral head with the ischiopubic fragment, as well as the posterior wall fragment. It is easy to see on this view how the femoral head may abrade against the fracture edge whereas the hip is subluxated. C: The iliac oblique view highlights the fracture line exiting the greater sciatic notch as well as the posterior wall fragment superimposed on the roof of the acetabulum (black arrow). D: This computed tomography section shows the posterior wall fracture (white arrow) with a column fracture line typical of a transverse fracture (black arrowheads).
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Anterior Column (or Wall) and Posterior Hemitransverse Acetabular Fractures.
The anterior plus posterior hemitransverse patterns involve either an anterior column or a wall fracture as the primary fracture line. An associated transverse fracture component propagates from the anterior fracture across the articular surface to the posterior border of the innominate bone. This posterior hemitransverse fracture is identical to the posterior half of a transverse fracture and may occur at any of the levels described above. The anterior plus posterior hemitransverse group makes up about 7% of fractures, over three quarters of which involve the anterior column rather than the wall.93,107,112 Radiographically, these fractures exhibit all the features of an anterior wall or column fracture but with displacement of the ilioischial line and a fracture line that crosses the posterior border of the bone on the iliac oblique. The displacement of the hemitransverse fracture component is generally less severe than that of the anterior fracture. However, the internal malrotation of the posterior column component may allow more anteromedial translation of the femoral head and striking displacements in comparison to the isolated anterior column fracture (Fig. 47-27). 
Figure 47-27
Radiographic appearance of the associated anterior wall and posterior hemitransverse fracture.
 
A: The anteroposterior pelvis radiograph demonstrates the medial subluxation of the femoral head with segmental displacement of the iliopectineal line. The ilioischial line displacement is noted and, unlike the anterior wall fracture, the relationship of the ischium to the ilioischial line is preserved. Wear of the femoral head is seen laterally where the head is articulating with the edge of the intact roof. B: The obturator oblique radiograph appears similar to that seen in the isolated anterior wall fracture but the fracture is seen to be multifragmentary with impaction. Disruption of the posterior rim line is appreciated. C: The iliac oblique shows the disruption of the posterior border of the innominate and displacement through the greater sciatic notch.
A: The anteroposterior pelvis radiograph demonstrates the medial subluxation of the femoral head with segmental displacement of the iliopectineal line. The ilioischial line displacement is noted and, unlike the anterior wall fracture, the relationship of the ischium to the ilioischial line is preserved. Wear of the femoral head is seen laterally where the head is articulating with the edge of the intact roof. B: The obturator oblique radiograph appears similar to that seen in the isolated anterior wall fracture but the fracture is seen to be multifragmentary with impaction. Disruption of the posterior rim line is appreciated. C: The iliac oblique shows the disruption of the posterior border of the innominate and displacement through the greater sciatic notch.
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Figure 47-27
Radiographic appearance of the associated anterior wall and posterior hemitransverse fracture.
A: The anteroposterior pelvis radiograph demonstrates the medial subluxation of the femoral head with segmental displacement of the iliopectineal line. The ilioischial line displacement is noted and, unlike the anterior wall fracture, the relationship of the ischium to the ilioischial line is preserved. Wear of the femoral head is seen laterally where the head is articulating with the edge of the intact roof. B: The obturator oblique radiograph appears similar to that seen in the isolated anterior wall fracture but the fracture is seen to be multifragmentary with impaction. Disruption of the posterior rim line is appreciated. C: The iliac oblique shows the disruption of the posterior border of the innominate and displacement through the greater sciatic notch.
A: The anteroposterior pelvis radiograph demonstrates the medial subluxation of the femoral head with segmental displacement of the iliopectineal line. The ilioischial line displacement is noted and, unlike the anterior wall fracture, the relationship of the ischium to the ilioischial line is preserved. Wear of the femoral head is seen laterally where the head is articulating with the edge of the intact roof. B: The obturator oblique radiograph appears similar to that seen in the isolated anterior wall fracture but the fracture is seen to be multifragmentary with impaction. Disruption of the posterior rim line is appreciated. C: The iliac oblique shows the disruption of the posterior border of the innominate and displacement through the greater sciatic notch.
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The associated anterior plus posterior hemitransverse and the isolated anterior column fractures are common fracture patterns seen in the elderly after a fall onto the hip. The fracture pattern is often complicated by impaction of the medial roof of the acetabulum and has been termed the “gull wing” sign based on the radiograph appearance on the AP radiograph (Fig. 47-28). The presence of this impaction is a poor prognostic sign.5 
Figure 47-28
The “gull wing” sign represents impaction of the acetabular roof (arrow) and is a poor prognostic sign.
 
Maintaining reduction of the impacted fragment is difficult and fragment displacement may allow recurrent subluxation of the femoral head and an incongruous hip joint.
Maintaining reduction of the impacted fragment is difficult and fragment displacement may allow recurrent subluxation of the femoral head and an incongruous hip joint.
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Figure 47-28
The “gull wing” sign represents impaction of the acetabular roof (arrow) and is a poor prognostic sign.
Maintaining reduction of the impacted fragment is difficult and fragment displacement may allow recurrent subluxation of the femoral head and an incongruous hip joint.
Maintaining reduction of the impacted fragment is difficult and fragment displacement may allow recurrent subluxation of the femoral head and an incongruous hip joint.
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T-Shaped Acetabular Fractures.
The T-shaped fracture represents approximately 7% of acetabular fractures and involves a transverse fracture with an associated inferior vertical fracture line known as the stem of the T.93,107,112 The vertical stem usually propagates from the transverse fracture, across the quadrilateral surface and cotyloid fossa, then enters the obturator foramen through the ischiopubic notch, and ends in a fracture of the ischial ramus, typically exiting through the ischiopubic ramus. However, it may also extend posteriorly (exiting through the ischium) or anteriorly (exiting near the pubic body). In any case, the caudal ischiopubic segment created by the transverse fracture component is divided into a posterior (ischial) and an anterior (pubic) articular segment. Radiographically, the identification of the transverse fracture in the presence of a fracture of the ischial ramus leads the surgeon to recognize the T-shaped fracture (Fig. 47-29). Diagnosis of the T-shaped fracture and recognition of columnar displacements, both in relation to the intact innominate bone and to each other, are crucial in treating the T-shaped fracture. The T-shaped fracture may also be associated with a posterior wall fracture. This subgroup of fractures is generally included in the transverse plus posterior wall pattern but has been noted to have the worst prognosis of any subgroup of fractures. Finally, fractures of the posterior column with anterior hemitransverse associated fractures are classified as T-shaped. 
Figure 47-29
Radiographic appearance of the T-shaped fracture of the patient shown in Figure 47-5.
 
A: The appearance on the anteroposterior pelvis radiograph may be distinguished from the transverse fracture by the presence of the fracture of the ischial ramus (white arrow). Displacement of the stem of the T may cause the ilioischial line to appear duplicated (black arrowheads). Likewise, the relationship between the ilioischial line, which remains with the posterior column, and the teardrop, which remains with the anterior column, may be disrupted (black arrow). B: The obturator oblique shows the break in the iliopectineal line (black arrow). It also allows better visualization of the stem of the T (white arrow) as it enters the roof of the obturator foramen and is associated with the ischial ramus fracture (arrowhead). C: The iliac oblique view demonstrates the disruption of the greater sciatic notch and subluxation of the femoral head.
 
(Copyright Berton R. Moed, MD.)
A: The appearance on the anteroposterior pelvis radiograph may be distinguished from the transverse fracture by the presence of the fracture of the ischial ramus (white arrow). Displacement of the stem of the T may cause the ilioischial line to appear duplicated (black arrowheads). Likewise, the relationship between the ilioischial line, which remains with the posterior column, and the teardrop, which remains with the anterior column, may be disrupted (black arrow). B: The obturator oblique shows the break in the iliopectineal line (black arrow). It also allows better visualization of the stem of the T (white arrow) as it enters the roof of the obturator foramen and is associated with the ischial ramus fracture (arrowhead). C: The iliac oblique view demonstrates the disruption of the greater sciatic notch and subluxation of the femoral head.
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Figure 47-29
Radiographic appearance of the T-shaped fracture of the patient shown in Figure 47-5.
A: The appearance on the anteroposterior pelvis radiograph may be distinguished from the transverse fracture by the presence of the fracture of the ischial ramus (white arrow). Displacement of the stem of the T may cause the ilioischial line to appear duplicated (black arrowheads). Likewise, the relationship between the ilioischial line, which remains with the posterior column, and the teardrop, which remains with the anterior column, may be disrupted (black arrow). B: The obturator oblique shows the break in the iliopectineal line (black arrow). It also allows better visualization of the stem of the T (white arrow) as it enters the roof of the obturator foramen and is associated with the ischial ramus fracture (arrowhead). C: The iliac oblique view demonstrates the disruption of the greater sciatic notch and subluxation of the femoral head.
(Copyright Berton R. Moed, MD.)
A: The appearance on the anteroposterior pelvis radiograph may be distinguished from the transverse fracture by the presence of the fracture of the ischial ramus (white arrow). Displacement of the stem of the T may cause the ilioischial line to appear duplicated (black arrowheads). Likewise, the relationship between the ilioischial line, which remains with the posterior column, and the teardrop, which remains with the anterior column, may be disrupted (black arrow). B: The obturator oblique shows the break in the iliopectineal line (black arrow). It also allows better visualization of the stem of the T (white arrow) as it enters the roof of the obturator foramen and is associated with the ischial ramus fracture (arrowhead). C: The iliac oblique view demonstrates the disruption of the greater sciatic notch and subluxation of the femoral head.
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Both-Column Acetabular Fractures.
The both-column fracture is the most common of the associated fractures making up 23% of all acetabular fractures.93,107,112 This fracture is unique in that it represents an acetabulum completely disconnected from the axial skeleton. By definition all both-column fractures have no portion of the acetabular articular surface remaining attached to the innominate bone and there is a split between an anterior and a posterior column component. Within this definition there is room for many different fracture patterns. In its most simple form an anterior column fracture may be associated with a simple posterior column fracture (Fig. 47-15). This is the exception and usually there are secondary fractures involving the anterior and posterior columns. Even in very comminuted associated both-column fractures, the acetabular labrum usually remains intact. Therefore, as the femoral head medializes because of muscular pull, the articular fragments may each rotate around, yet remain congruent to the femoral head (Fig. 47-30). This creates a situation unique to both-column fractures that is known as “secondary congruence.”93,181 The radiograph “spur sign” when present, is pathognomonic for the associated both-column fracture.93 This is seen best on the obturator oblique projection and represents the external cortex of the most caudal portion of the intact ilium (Fig. 47-31). It is generally seen only in the both-column fracture because the femoral head medializes with all portions of the acetabular articular surface. The surgeon should recognize that transverse fractures, transverse and posterior wall fractures, T-shaped fractures, and anterior/posterior hemitransverse fractures all involve the anterior and posterior columns of the acetabulum, but are not “both-column” fractures. In these four fracture types a portion of the articular surface remains intact with the ilium.93 It is also common for the both-column fracture to have a posterior superior wall fracture component (Figs. 47-31D and 47-32A, B). 
Figure 47-30
Drawing showing how the free articular fragments in a both-column fracture may each rotate around, yet remain congruent to, the femoral head.
 
(From Matta JM. Operative indications and choice of surgical approach for fractures of the acetabulum. Tech Orthop. 1986;1:14.)
(From Matta JM. Operative indications and choice of surgical approach for fractures of the acetabulum. Tech Orthop. 1986;1:14.)
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Figure 47-30
Drawing showing how the free articular fragments in a both-column fracture may each rotate around, yet remain congruent to, the femoral head.
(From Matta JM. Operative indications and choice of surgical approach for fractures of the acetabulum. Tech Orthop. 1986;1:14.)
(From Matta JM. Operative indications and choice of surgical approach for fractures of the acetabulum. Tech Orthop. 1986;1:14.)
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Figure 47-31
Radiographic appearance of a both-column fracture.
 
A: Despite disruption of all six of the radiograph landmarks, the femoral head is seen to remain congruent to the roof and the anterior column fragment. The position of the head on the anteroposterior radiograph is medialized as well as superiorly displaced. Fracture of the contralateral pubic body because of the displacement of the superior pubic ramus fragment is noted. B: The obturator oblique demonstrates the spur sign (arrowhead) as well as confirming the congruence between the femoral head and the acetabulum. C: The iliac oblique view reveals loss of congruence between the femoral head and the posterior column; therefore, this fracture is indicated for surgical treatment. D: The computed tomography section shows the anterior column (white arrow), the superior extent of the posterior column (white arrowhead), the spur sign of the iliac wing (black arrow), and a large posterior wall fracture (black arrowhead).
 
(Copyright Berton R. Moed, MD.)
A: Despite disruption of all six of the radiograph landmarks, the femoral head is seen to remain congruent to the roof and the anterior column fragment. The position of the head on the anteroposterior radiograph is medialized as well as superiorly displaced. Fracture of the contralateral pubic body because of the displacement of the superior pubic ramus fragment is noted. B: The obturator oblique demonstrates the spur sign (arrowhead) as well as confirming the congruence between the femoral head and the acetabulum. C: The iliac oblique view reveals loss of congruence between the femoral head and the posterior column; therefore, this fracture is indicated for surgical treatment. D: The computed tomography section shows the anterior column (white arrow), the superior extent of the posterior column (white arrowhead), the spur sign of the iliac wing (black arrow), and a large posterior wall fracture (black arrowhead).
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Figure 47-31
Radiographic appearance of a both-column fracture.
A: Despite disruption of all six of the radiograph landmarks, the femoral head is seen to remain congruent to the roof and the anterior column fragment. The position of the head on the anteroposterior radiograph is medialized as well as superiorly displaced. Fracture of the contralateral pubic body because of the displacement of the superior pubic ramus fragment is noted. B: The obturator oblique demonstrates the spur sign (arrowhead) as well as confirming the congruence between the femoral head and the acetabulum. C: The iliac oblique view reveals loss of congruence between the femoral head and the posterior column; therefore, this fracture is indicated for surgical treatment. D: The computed tomography section shows the anterior column (white arrow), the superior extent of the posterior column (white arrowhead), the spur sign of the iliac wing (black arrow), and a large posterior wall fracture (black arrowhead).
(Copyright Berton R. Moed, MD.)
A: Despite disruption of all six of the radiograph landmarks, the femoral head is seen to remain congruent to the roof and the anterior column fragment. The position of the head on the anteroposterior radiograph is medialized as well as superiorly displaced. Fracture of the contralateral pubic body because of the displacement of the superior pubic ramus fragment is noted. B: The obturator oblique demonstrates the spur sign (arrowhead) as well as confirming the congruence between the femoral head and the acetabulum. C: The iliac oblique view reveals loss of congruence between the femoral head and the posterior column; therefore, this fracture is indicated for surgical treatment. D: The computed tomography section shows the anterior column (white arrow), the superior extent of the posterior column (white arrowhead), the spur sign of the iliac wing (black arrow), and a large posterior wall fracture (black arrowhead).
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Figure 47-32
Three-dimensional computed tomogram in a both-column fracture showing the separate posterior wall component with the edge of the fracture line highlighted with black and white dots.
A: Surface-rendered image. B: Volume-rendered image.
(Copyright Berton R. Moed, MD.)
A: Surface-rendered image. B: Volume-rendered image.
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Outcome Measures for Acetabular Fractures

The most generally accepted method system for grading clinical outcome after an acetabular fracture is a modification of the Merle d’Aubigné hip score.93,107,121 The original grading method, which was described by Merle d’Aubigné and Postel,117 was published in the English language in 1954. The widespread use and acceptance of this evaluation method resulted from the publications of Letournel and Judet in which its use for grading acetabular fracture outcome was described.93,120 In this clinical grading system, pain, gait, and the range of motion of the hip are each assigned a maximum score of 6 points. The three individual scores are summed to derive the final clinical score. This score is classified as excellent (18 points), very good (17 points), good (15 or 16 points), fair (13 or 14 points), or poor (<13 points). The current grading (Table 47-4) incorporates more demanding criteria for range of motion than described by Letournel and Judet.107,120,121 Commonly, the clinical outcome is dichotomized into good-to-excellent and fair-to-poor categories to describe the results. Radiographic outcome has been shown to be related to this clinical outcome measure and is described as excellent (a normal appearing hip joint), good (mild changes with minimal sclerosis and joint narrowing ≤1 mm), fair (intermediate changes with moderate sclerosis and joint narrowing <50%), and poor (advanced changes).93,107,120,148 However, these clinical methods have not been scientifically developed or validated. These methods are useful for evaluating isolated hip function in patients who have been treated for an acetabular fracture.127 Nonetheless, their shortcomings limit their usefulness as methods for evaluating overall functional outcome in these patients. Therefore, despite the common practice of using such clinical measures to evaluate the outcomes in patients with orthopedic conditions, a validated, self-reported patient questionnaire is most useful for determining health status.150,176 
Table 47-4
The Modified Merle d’Aubigné and Postel Clinical Grading Systema
Parameter Points
Pain
  •  
    None
  •  
    Slight or intermittent
  •  
    After walking but resolves
  •  
    Moderately severe but patient is able to walk
  •  
    Severe, prevents walking
6
5
4
3
2
Walking
  •  
    Normal
  •  
    No cane but slight limp
  •  
    Long distance with cane or crutch
  •  
    Limited even with support
  •  
    Very limited
  •  
    Unable to walk
6
5
4
3
2
1
Range of motionb 6
5
4
3
2
1
Clinical scorec 18
17
15 or 16
13 or 14
<13
X
The Musculoskeletal Function Assessment (MFA) is a 101-item self-administered health status instrument designed for patients with disorders or injuries of the musculoskeletal system.42,104,176 It has been shown to be stable and to have internal consistency, content validity, and criterion validity.176 It has also been used to evaluate functional outcome in relatively large series of acetabular fracture patients treated operatively.87,127,131 It is important to note that the normal population reference values for the MFA were derived from a relatively small sample of hospital employees and other individuals visiting the authors’ medical center and actually may not represent a normative population.43,113 Recent study suggests that this previously reported “normative” information may be incorrect and/or that temporal and geographic conditions may influence normative data.113 The Short Form-36 and Life Satisfaction-11 have been used to evaluate the quality of life in acetabular fracture patients.15 In any case, it is important to remember that outcome instruments, such as the MFA, are designed to measure the overall patient function from the individual’s perspective, and not to replace traditional physician-oriented clinical outcome measures.9 More recently, outcome has been measured by means of survivorship of the hip, using conversion to hip fusion or total hip arthroplasty as an indirect marker for the development of posttraumatic osteoarthritis.48,178 

Pathoanatomy and Applied Anatomy Relating to Acetabular Fractures

The innominate bone is formed as a condensation of pubis, ischium, and ilium at the triradiate cartilage, which fuse at the time of skeletal maturity. The plane of the ilium is approximately 90 degrees to the plane of the obturator foramen and the articular surface of the acetabulum can be visualized as being supported between the two limbs of an inverted “Y” of bone.93 The anterior column refers to the anterior limb of the inverted “Y” and consists of the anterior half of the iliac wing that is contiguous with the pelvic brim to the superior pubic ramus, as well as the anterior half of the acetabular articular surface. The posterior column (posterior limb of the inverted “Y”) begins at the superior aspect of the greater sciatic notch and is contiguous with the greater and lesser sciatic notches inferiorly and includes the ischial tuberosity. These two columns of bone are, in turn, connected to the sacroiliac articulation by a thick strut of bone lying above the greater sciatic notch, known as the sciatic buttress (Fig. 47-7). The two columns meet medially to form the quadrilateral plate, which is the internal cortical surface of the acetabulum. Fractures through this region commonly result in rotational displacements, correction of which is a critical part of acetabular fracture surgery. The superior portion of the acetabular articular surface is often referred to as the weight-bearing dome or roof.181 This region extends from just posterior to the anterior inferior iliac spine to the superior aspect of the posterior column.93,181 Fracture displacements through this region have great clinical importance, as they must be anatomically reduced.93,107,181 The anterior and posterior walls of the acetabulum are components of the respective columns (Fig. 47-8). 
Successful treatment of an acetabular fracture is based not only on a thorough understanding of the three-dimensional morphology of the innominate bone, but also on knowledge and appreciation of the surrounding soft tissue anatomy (Fig. 47-33). The close proximity of major neurovascular structures places them at risk at the time of the fracture trauma, as well as during operative approaches and fracture fixation. The blood supply to the innominate bone is quite extensive (Fig. 47-34). Nonetheless, its interruption can occur from injury compounded by excessive dissection or periosteal stripping during surgery. The blood supply to the external surface is mainly derived from the superior gluteal artery, along with the inferior gluteal artery, the obturator artery, and the medial femoral circumflex artery.71 The blood supply to the internal surface is derived from the fourth lumbar, iliolumbar, and obturator arteries.71 The main nutrient artery to the ilium, which usually originates from the iliolumbar artery (a main branch of the posterior trunk of the internal iliac artery), serves as a main blood supply to the supra-acetabular region.71,75 The blood supply to the supra-acetabular bone is dependent on the nutrient artery to the ilium and branches of the superior gluteal artery (Fig. 47-34).71 The blood supply to the posterior wall is dependent on the branches of the superior and inferior gluteal arteries (Fig. 47-34).71 
Figure 47-33
Transverse section through the thigh at the level of the hip joint.
 
Note the close proximity of the femoral artery and vein to the anterior aspect of the hip joint and head of the femur. Note also the proximity of the sciatic nerve and gluteal vessels to the posterior aspect of the hip joint separated only by the gemelli and obturator internus muscles.
 
(Modified from: Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003; originally from Anderson IE. Grant’s Atlas of Anatomy, 8th ed. Baltimore, MD: Williams & Wilkins; 1983, Figure 3-7, page 27.)
Note the close proximity of the femoral artery and vein to the anterior aspect of the hip joint and head of the femur. Note also the proximity of the sciatic nerve and gluteal vessels to the posterior aspect of the hip joint separated only by the gemelli and obturator internus muscles.
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Figure 47-33
Transverse section through the thigh at the level of the hip joint.
Note the close proximity of the femoral artery and vein to the anterior aspect of the hip joint and head of the femur. Note also the proximity of the sciatic nerve and gluteal vessels to the posterior aspect of the hip joint separated only by the gemelli and obturator internus muscles.
(Modified from: Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003; originally from Anderson IE. Grant’s Atlas of Anatomy, 8th ed. Baltimore, MD: Williams & Wilkins; 1983, Figure 3-7, page 27.)
Note the close proximity of the femoral artery and vein to the anterior aspect of the hip joint and head of the femur. Note also the proximity of the sciatic nerve and gluteal vessels to the posterior aspect of the hip joint separated only by the gemelli and obturator internus muscles.
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Figure 47-34
 
A: Diagram of the blood supply to the external side of the acetabulum of a right hip. For reason of simplicity the medial femoral circumflex artery and its branches to the anterior inferior acetabulum are omitted. B: Intrapelvic blood supply. The schematic drawing includes the blood vessels important to the acetabular blood supply; visceral arteries are omitted. In hips, where the nutrient artery enters medial to the pelvic brim, the inferior ramus of the iliolumbar artery originates directly from the obturator artery.
 
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)
A: Diagram of the blood supply to the external side of the acetabulum of a right hip. For reason of simplicity the medial femoral circumflex artery and its branches to the anterior inferior acetabulum are omitted. B: Intrapelvic blood supply. The schematic drawing includes the blood vessels important to the acetabular blood supply; visceral arteries are omitted. In hips, where the nutrient artery enters medial to the pelvic brim, the inferior ramus of the iliolumbar artery originates directly from the obturator artery.
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Figure 47-34
A: Diagram of the blood supply to the external side of the acetabulum of a right hip. For reason of simplicity the medial femoral circumflex artery and its branches to the anterior inferior acetabulum are omitted. B: Intrapelvic blood supply. The schematic drawing includes the blood vessels important to the acetabular blood supply; visceral arteries are omitted. In hips, where the nutrient artery enters medial to the pelvic brim, the inferior ramus of the iliolumbar artery originates directly from the obturator artery.
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003.)
A: Diagram of the blood supply to the external side of the acetabulum of a right hip. For reason of simplicity the medial femoral circumflex artery and its branches to the anterior inferior acetabulum are omitted. B: Intrapelvic blood supply. The schematic drawing includes the blood vessels important to the acetabular blood supply; visceral arteries are omitted. In hips, where the nutrient artery enters medial to the pelvic brim, the inferior ramus of the iliolumbar artery originates directly from the obturator artery.
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The main blood supply of the femoral head is the deep branch of the medial femoral circumflex artery.50 Knowledge of the extracapsular anatomy of this artery and its surrounding structures will help to avoid iatrogenic avascular necrosis of the head of the femur during posterior surgical approaches to the acetabulum (Fig. 47-35). The deep branch of the medial femoral circumflex artery is protected by the obturator externus tendon.50 Therefore, disruption of this tendon by traumatic injury or surgery places the blood supply to the femoral head at great risk. 
Figure 47-35
Diagram showing the course of the deep branch of the medial femoral circumflex artery with respect to the tendons of the (a) obturator externus and (b) obturator internus.
 
Shown are the distances of the deep branch of the artery to the trochanteric crest at the level of the lesser trochanter (A = 18.2 mm), insertion of the obturator externus (B = 8.8 mm), and the insertion of the obturator internus (C = 1.24 mm).
 
(Redrawn after Helfet DL, Beck M, Gautier E, et al. Surgical techniques for acetabular fractures. In: Tile M, Helfet DL, Kellam JF, eds. Fractures of the Pelvis and Acetabulum. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:537.)
Shown are the distances of the deep branch of the artery to the trochanteric crest at the level of the lesser trochanter (A = 18.2 mm), insertion of the obturator externus (B = 8.8 mm), and the insertion of the obturator internus (C = 1.24 mm).
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Figure 47-35
Diagram showing the course of the deep branch of the medial femoral circumflex artery with respect to the tendons of the (a) obturator externus and (b) obturator internus.
Shown are the distances of the deep branch of the artery to the trochanteric crest at the level of the lesser trochanter (A = 18.2 mm), insertion of the obturator externus (B = 8.8 mm), and the insertion of the obturator internus (C = 1.24 mm).
(Redrawn after Helfet DL, Beck M, Gautier E, et al. Surgical techniques for acetabular fractures. In: Tile M, Helfet DL, Kellam JF, eds. Fractures of the Pelvis and Acetabulum. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:537.)
Shown are the distances of the deep branch of the artery to the trochanteric crest at the level of the lesser trochanter (A = 18.2 mm), insertion of the obturator externus (B = 8.8 mm), and the insertion of the obturator internus (C = 1.24 mm).
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Acetabular Fracture Treatment Options

Nonoperative Treatment of Acetabular Fractures

In general, all stable concentrically reduced acetabular fractures not involving the superior acetabular dome can be considered for nonoperative management.67,108,143,156,181 This group of fractures includes nondisplaced and minimally displaced fractures, fractures in which the intact part of the acetabulum is large enough to maintain stability and congruity, and those with secondary congruence (Table 47-5). Nonoperative management may also be selected for patients with severe underlying medical problems that preclude surgical intervention. This is a relatively small group, consisting mainly of elderly patients. 
 
Table 47-5
Acetabular Fractures Nonoperative Treatment
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Table 47-5
Acetabular Fractures Nonoperative Treatment
Indications Relative Contraindications
Stable nondisplaced fractures Hip joint instability
Stable and congruous minimally displaced fractures Hip joint incongruity
Selected displaced fractures
Intact acetabulum maintains stability and congruity
Low anterior column fractures
Low transverse fractures
Low T-shaped fractures
Both-column fractures with secondary congruence
Wall fracture not compromising hip stability
Infirm patients unable to withstand surgery
Severe osteoporosis precluding fracture fixation
X
Rowe and Lowell156 first recognized the condition of the superior dome of the acetabulum to be a significant prognostic indicator of clinical outcome. The superior dome or roof of the acetabulum is described as the superior third of the weight-bearing area of the acetabulum and has been further quantified by other investigators. Olson and Matta143 demonstrated that axial CT sections of the superior 10 mm of the acetabular articular surface are equivalent to the weight-bearing dome region and can also be useful in determining if acetabular fracture lines involve this region. Although controversy exists regarding the exact amount of displacement that is considered acceptable when the superior dome of the acetabulum is involved, most authors recommend surgical intervention if displacement exceeds 2 mm.67,93,107,143 
Matta et al.108 developed roof arc measurements to determine whether an acetabular fracture has violated the weight-bearing dome. This measurement has been used to determine if the remaining intact acetabulum is sufficient to maintain a stable and congruous relationship with the femoral head. In this way, operative versus nonoperative treatment can be selected. The roof arc is measured on all three radiograph views with the leg out of traction. The medial roof arc is measured on the AP view. The anterior roof arc is measured on the obturator oblique, and the posterior roof arc is measured on the iliac oblique. To obtain these measurements, the first line is a vertical line through the center of the femoral head and the second line is drawn from the center of the femoral head to the fracture location at the articular surface (Fig. 47-36). Roof arc measurements are not applicable to both-column fractures or those with a fracture of the posterior wall. The previous recommendations were that roof arc measurements greater than 45 degrees on the AP (medial roof arc), iliac oblique (posterior roof arc), and obturator oblique radiographs (anterior roof arc) indicate preservation of the weight-bearing dome, and these patients should be considered for nonoperative management.110,143 However, subsequent biomechanical study187 produced different criteria; fractures with a medial roof arc angle of greater than 45 degrees, an anterior roof arc angle of greater than 25 degrees, and a posterior roof arc angle of greater than 70 degrees have sufficient intact acetabulum for nonoperative treatment (Fig. 47-36). More recent biomechanical study suggests that with the acetabulum subjected to sit-to-stand loading, rather than single-leg-stance loading, the critical angles are significantly higher, requiring a medial roof arc of 90.9 degrees, an anterior roof arc of 67.3 degrees, and a posterior roof arc of 101.4 degrees.105 The clinical implications of these newer findings are yet to be determined. In any case, displaced low anterior column, low transverse, and low T-shaped acetabular fractures are amenable to nonoperative treatment, if, as expected, the fracture position is stable and the joint remains congruent53,77,114,133 (Table 47-5). 
Figure 47-36
 
A: Anteroposterior (AP), (B) obturator oblique, and (C). iliac oblique radiographs of a transverse fracture of the acetabulum showing roof arcs of approximately 50 degrees each, indicative of a stable hip joint by the initial recommendations (greater than 45 degrees on each view).110 D: AP radiograph of the patient obtained 3 weeks later showing gross medial subluxation of the hip, which would have been expected using the updated criteria for stability of Vrahas et al.187 (greater than 45 degrees on AP, greater than 25 degrees on obturator oblique, greater than 70 degrees on iliac oblique).
 
(Copyright Berton R. Moed, MD.)
A: Anteroposterior (AP), (B) obturator oblique, and (C). iliac oblique radiographs of a transverse fracture of the acetabulum showing roof arcs of approximately 50 degrees each, indicative of a stable hip joint by the initial recommendations (greater than 45 degrees on each view).110 D: AP radiograph of the patient obtained 3 weeks later showing gross medial subluxation of the hip, which would have been expected using the updated criteria for stability of Vrahas et al.187 (greater than 45 degrees on AP, greater than 25 degrees on obturator oblique, greater than 70 degrees on iliac oblique).
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Figure 47-36
A: Anteroposterior (AP), (B) obturator oblique, and (C). iliac oblique radiographs of a transverse fracture of the acetabulum showing roof arcs of approximately 50 degrees each, indicative of a stable hip joint by the initial recommendations (greater than 45 degrees on each view).110 D: AP radiograph of the patient obtained 3 weeks later showing gross medial subluxation of the hip, which would have been expected using the updated criteria for stability of Vrahas et al.187 (greater than 45 degrees on AP, greater than 25 degrees on obturator oblique, greater than 70 degrees on iliac oblique).
(Copyright Berton R. Moed, MD.)
A: Anteroposterior (AP), (B) obturator oblique, and (C). iliac oblique radiographs of a transverse fracture of the acetabulum showing roof arcs of approximately 50 degrees each, indicative of a stable hip joint by the initial recommendations (greater than 45 degrees on each view).110 D: AP radiograph of the patient obtained 3 weeks later showing gross medial subluxation of the hip, which would have been expected using the updated criteria for stability of Vrahas et al.187 (greater than 45 degrees on AP, greater than 25 degrees on obturator oblique, greater than 70 degrees on iliac oblique).
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Roof arc measurements are not applicable to both-column fractures because there is no intact portion of the acetabulum to measure. Instead, displaced both-column fractures of the acetabulum may be considered for nonoperative management in the presence of secondary congruence (Fig. 47-37), defined as congruency between the femoral head and the displaced acetabular articular fragments without skeletal traction being applied.93 Parallelism between the femoral head and acetabular articular surface must be maintained in all three radiographic views, especially in a young patient. However, secondary congruence is a necessary, but not a sufficient, criterion for nonsurgical treatment. In addition, articular fragment displacement and medial joint displacement should not be so excessive as to limit motion, and limb shortening must be acceptable. It must be recognized that fractures with secondary congruence do not have as good a prognosis as those reduced in anatomic position.93,97,107 
Figure 47-37
Both-column fracture showing secondary congruence.
 
A: Anteroposterior, (B) obturator oblique, with white arrow showing the spur sign, and (C) iliac oblique radiographs at the time of injury. D: Obturator oblique radiograph 14 years later in a patient with an excellent clinical result.
 
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:507–508.)
A: Anteroposterior, (B) obturator oblique, with white arrow showing the spur sign, and (C) iliac oblique radiographs at the time of injury. D: Obturator oblique radiograph 14 years later in a patient with an excellent clinical result.
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Figure 47-37
Both-column fracture showing secondary congruence.
A: Anteroposterior, (B) obturator oblique, with white arrow showing the spur sign, and (C) iliac oblique radiographs at the time of injury. D: Obturator oblique radiograph 14 years later in a patient with an excellent clinical result.
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003:507–508.)
A: Anteroposterior, (B) obturator oblique, with white arrow showing the spur sign, and (C) iliac oblique radiographs at the time of injury. D: Obturator oblique radiograph 14 years later in a patient with an excellent clinical result.
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Roof arc measurements are also not applicable to fractures of the posterior wall. Fractures involving the acetabular walls can be treated nonoperatively only if the hip joint remains completely stable.56 Currently, there is no method for interpretation of the routine static imaging studies to reliably determine hip stability status in all cases.36,56,119,152 Using two-dimensional CT to measure posterior wall size, fractures involving more than 50% of the articular surface can reliably considered to be unstable; however, fractures involving between 20% and 50% are indeterminate.119,152 Although previously it had been thought that fractures involving less than 20% of the posterior wall are stable, it has been shown that hip instability can be present in a small percentage of these cases.152 In addition, an acetabular wall fracture presenting in the absence of known hip dislocation is no guarantee of hip stability and conversely, a history of an associated hip dislocation is not a reliable indicator of persistent hip instability.56,119 Although further study is needed, it appears that a specifically described dynamic stress examination under anesthesia is a diagnostic study that can define the hip stability status and the need for operative intervention of fractures of the posterior wall (Fig. 47-14).56,119,134 When in doubt, it is safest to assume that all of these fractures are unstable until proved otherwise.36 Therefore, clinical evaluation of stability is mandatory if nonoperative treatment is being considered. As noted previously, this examination is best performed using fluoroscopic visualization of the hip joint, with the patient under general anesthesia.56,119,183 
It may seem obvious that all nondisplaced and minimally displaced acetabular fractures should be considered for nonoperative management. However, there have been advocates for percutaneous fracture fixation in this group of patients.35,80,169 The concern centers on the questionable stability of these fractures with the contention that a certain percentage will displace. Therefore, early percutaneous fixation would avoid a subsequent more extensive open procedure or prevent the disaster of early traumatic arthritis in those (for whatever reason) not having the benefit of further treatment. However, only a very small number (less than 7%) of these nondisplaced and minimally displaced fractures are potentially unstable and will significantly displace without traction.183 Rather than unnecessarily operating on a large number of fractures to prevent problems in these few, it would be better to identify those at substantial risk for fracture displacement. Dynamic fluoroscopic stress examination with the patient under general anesthesia, as noted earlier, is one proposed method of identifying these fractures at risk.183 However, the exact technique for performing this examination is ill-defined for fractures other than the posterior wall. Another method is to closely observe all patients presenting with nonoperative parameters via weekly radiographic follow-up, being prepared to shift immediately to operative management (percutaneous or otherwise) should joint instability or incongruency be detected. 
Prerequisites for nonoperative treatment of acetabulum fractures include both intact roof arc measurements and congruence of the femoral head to the intact acetabulum on AP and Judet radiographs obtained out of traction. Patient-related factors such as age, preinjury activity level, functional demands, and medical comorbidities also must be considered when determining whether a patient is best served by operative or nonoperative treatment. Nonoperative treatment of elderly or infirm patients or those with severe osteoporosis precluding adequate fracture fixation, with planned subsequent arthroplasty if symptomatic arthritis develops, may be appropriate—particularly if the fracture displacement is minimal.72,162,166,181 

Techniques

For patients with acetabular fractures meeting criteria for nonoperative management, treatment mainly consists of bed rest with joint mobilization and eventual progression to full weight-bearing activity. Bed rest is necessary in the acute injury phase only for symptomatic relief. Mobilization of the patient and the hip joint should follow as soon as symptoms allow. Patients should begin with touch-down partial weight-bearing of the affected extremity (less than 10 kg). AP and oblique radiographs should be obtained at frequent intervals (weekly for the first 4 weeks) to confirm maintenance of satisfactory position. When there is adequate fracture healing, usually by 6 to 12 weeks, the patient should gradually progress to full weight bearing. Joint mobilization should be continued throughout the rehabilitation period. The use of formal physiotherapy or continuous passive motion modalities should be tailored to the individual. 
Prolonged traction treatment should be considered only for those patients with operative indications related to fracture displacement but having contraindications to surgical intervention. In these cases, traction should be maintained until fracture healing is sufficient to allow progressive weight-bearing ambulation and may range from 4 to 12 weeks.179,181 

Outcomes

Fractures fulfilling the criteria described earlier can be treated nonoperatively with good results. In the study by Rowe and Lowell156 in 1961, the 49 patients with nondisplaced linear fractures or displaced medial wall fractures not involving the superior dome were treated without surgery. At an average of 6 years follow-up, all patients with linear nondisplaced fractures and 26 of 28 patients with medial wall fractures demonstrated good or excellent clinical results. However, fractures of the superior acetabular dome or posterior acetabulum yielded variable results. Nondisplaced superior dome fractures treated by closed means yielded 75% good or excellent clinical results, whereas displaced fractures yielded 75% poor clinical results. Sixty-seven percent of posterior acetabular fractures treated nonoperatively had a poor clinical outcome. Delayed reduction of the hip dislocation, injury to the femoral head, and continued instability were all factors contributing to a poor outcome in patients with posterior acetabular fractures. Although their clinical outcome criteria are much different than those employed today, there are many similarities. An excellent clinical result was defined as a patient taking no medication with no symptoms, having full hip motion, walking without support and no limp, who returned to full activities and their original job.149 A good result was similar with the exceptions of the patient having minor complaints and loss of 25% of hip motion.149 
Letournel and Judet93 using the clinical outcome measure of the Merle d’Aubigné reported 83% good or excellent results in cases in which congruency could be obtained and maintained by closed means, with an average follow-up of 10 years. However, considerably worse results were observed in patients with unsatisfactorily reduced fractures involving the weight-bearing dome. Tornetta183 also demonstrated that satisfactory results could be achieved with nonoperative management provided joint congruence and stability are maintained. Thirty-eight patients with stable and congruent fractures as documented by dynamic fluoroscopic stress views were treated nonoperatively and followed for an average of 2.7 years. The patients were assessed by the modified Merle d’Aubigné score.107 The results were good or excellent in 35, and the three fair results were attributable to other, associated injuries. 

Operative Treatment of Acetabular Fractures

Indications/Contraindications

Operative treatment is indicated for all acetabular fractures that result in hip joint instability and/or incongruity, regardless of the classification type. This statement applies to displaced fractures as well as to those with occult findings. Posterior and anterior wall fractures with instability of the hip joint require operative fixation, as do injuries with fragments of bone or soft tissue incarcerated within the hip joint resulting in joint incongruity (Fig. 47-38). Open reduction and removal of the loose body or obstructive tissue is indicated to prevent early onset of traumatic arthritis. Internal fixation should be performed in this setting as dictated by hip joint stability parameters. Recurrent dislocation (with attendant disastrous consequences for the hip joint) is inevitable if stability is not restored.38 As has been previously described, two-dimensional CT as a means to determine hip joint stability has proved to be unreliable and it is safest to assume that all of these fractures are unstable unless proved otherwise by dynamic stress examination.36,56,119,152 In addition, there is no need to stress an obviously unstable hip. 
Figure 47-38
Initial (A) and postreduction (B) anteroposterior radiographs of the right hip in a 34-year-old man.
 
The postreduction view (B) demonstrates an incongruent hip joint with a probable intra-articular osteochondral fragment (arrow).
 
(Copyright Berton R. Moed, MD.)
The postreduction view (B) demonstrates an incongruent hip joint with a probable intra-articular osteochondral fragment (arrow).
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Figure 47-38
Initial (A) and postreduction (B) anteroposterior radiographs of the right hip in a 34-year-old man.
The postreduction view (B) demonstrates an incongruent hip joint with a probable intra-articular osteochondral fragment (arrow).
(Copyright Berton R. Moed, MD.)
The postreduction view (B) demonstrates an incongruent hip joint with a probable intra-articular osteochondral fragment (arrow).
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Fracture displacement in the weight-bearing dome results in joint incongruity and constitutes one of the main indications for open reduction and internal fixation. As described earlier, plain radiography and CT can be effectively used to determine whether an acetabular fracture violates the weight-bearing dome.110,143,187 A both-column fracture may exhibit significant displacement but with secondary congruence may not require operative treatment (Fig. 47-37). However, loss of parallelism between the femoral head and acetabular articular surface noted on any of the three radiographic views is an indication for operative management (Fig. 47-31). 
Osteoporosis precluding adequate fracture fixation and fractures in the geriatric population are commonly cited as relative contraindications to open reduction and internal fixation.181 In one series of patients with posterior wall fractures, for example, those 55 years of age or older having severe fracture comminution (defined as three or more fragments) had a poor prognosis.121 In situations in which nonoperative treatment is not a satisfactory option, such as an unstable hip joint, total hip arthroplasty or percutaneous fixation should be considered.10,48,178 Unfortunately, the determination of which patient would be best suited for surgery other than open reduction and internal fixation has not had specific guidelines and, therefore, has been very subjective. Recently, in a series reporting on 816 patients, factors were identified that were predictive of the need for early conversion to total hip arthroplasty.178 These factors were (1) an age of over 40 years, (2) anterior dislocation, (3) femoral head cartilage lesion, (4) involvement of the posterior wall, (5) marginal impaction, (6) initial displacement of greater than 20 mm, (7) nonanatomical reduction, (8) postoperative incongruence of the acetabular roof, and (9) utilization of the extended iliofemoral approach.178 A nomogram was constructed to help in selecting patients who could potentially benefit from acute primary total hip arthroplasty, by predicting the need for a total hip arthroplasty by 2 years after open reduction and fixation (Fig. 47-39).178 
Figure 47-39
Nomogram predicting the early need for total hip arthroplasty (or hip arthrodesis) within 2 years postoperatively.
 
To use the nomogram, locate the age axis and draw a line straight upward to the “Points scale” at the top to determine how many points the patient receives on the basis of his or her age. Repeat this process for each of the other predictor variables, then sum the points for the individual predictors. Locate this sum on the “Total Points” axis and draw a line straight downward to identify the predicted probability of the need for total hip arthroplasty within 2 years postoperatively.
 
(From: Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Am. 2012;94:1559-1567, Figure 3, page 1565. Permission granted.)
To use the nomogram, locate the age axis and draw a line straight upward to the “Points scale” at the top to determine how many points the patient receives on the basis of his or her age. Repeat this process for each of the other predictor variables, then sum the points for the individual predictors. Locate this sum on the “Total Points” axis and draw a line straight downward to identify the predicted probability of the need for total hip arthroplasty within 2 years postoperatively.
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Figure 47-39
Nomogram predicting the early need for total hip arthroplasty (or hip arthrodesis) within 2 years postoperatively.
To use the nomogram, locate the age axis and draw a line straight upward to the “Points scale” at the top to determine how many points the patient receives on the basis of his or her age. Repeat this process for each of the other predictor variables, then sum the points for the individual predictors. Locate this sum on the “Total Points” axis and draw a line straight downward to identify the predicted probability of the need for total hip arthroplasty within 2 years postoperatively.
(From: Tannast M, Najibi S, Matta JM. Two to twenty-year survivorship of the hip in 810 patients with operatively treated acetabular fractures. J Bone Joint Surg Am. 2012;94:1559-1567, Figure 3, page 1565. Permission granted.)
To use the nomogram, locate the age axis and draw a line straight upward to the “Points scale” at the top to determine how many points the patient receives on the basis of his or her age. Repeat this process for each of the other predictor variables, then sum the points for the individual predictors. Locate this sum on the “Total Points” axis and draw a line straight downward to identify the predicted probability of the need for total hip arthroplasty within 2 years postoperatively.
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General Considerations in Preoperative Planning

Preoperative Planning Considering Fracture Classification.
Classification of the fracture and subsequent preoperative planning are important and necessary aspects of the operative treatment process.93,144 Use of a specific algorithm for classifying acetabular fractures has been shown to be helpful for those with less experience treating these injuries, and a step-by-step method has been proposed for this purpose (Fig. 47-40).98 However, with 10 main fracture types in a classification used to describe a wide spectrum of injury, there are many transitional fracture configurations that do not exactly fit into one of the categories. Therefore, it is imperative, not only to classify each fracture, but also to recognize each fracture line. Definition of this entire fracture pattern is enhanced by drawing the fracture lines from the radiographic landmarks onto a dry bone model or by making a line drawing of the pelvis as seen on each radiographic view (Fig. 47-41). 
Figure 47-40
Algorithm proposed to facilitate fracture classification.
 
(From: Ly TV, Stover MD, Sims SH, et al. The use of an algorithm for classifying acetabular fractures. Clin Orthop Relat Res. 2011;469:2371–2376, Figure 4, page 2373. Permission granted.)
(From: Ly TV, Stover MD, Sims SH, et al. The use of an algorithm for classifying acetabular fractures. Clin Orthop Relat Res. 2011;469:2371–2376, Figure 4, page 2373. Permission granted.)
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Figure 47-40
Algorithm proposed to facilitate fracture classification.
(From: Ly TV, Stover MD, Sims SH, et al. The use of an algorithm for classifying acetabular fractures. Clin Orthop Relat Res. 2011;469:2371–2376, Figure 4, page 2373. Permission granted.)
(From: Ly TV, Stover MD, Sims SH, et al. The use of an algorithm for classifying acetabular fractures. Clin Orthop Relat Res. 2011;469:2371–2376, Figure 4, page 2373. Permission granted.)
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Figure 47-41
 
A: Anteroposterior and oblique radiographs show a juxtatectal transverse acetabular fracture with an associated posterior wall fracture. B: Selected axial computed tomography sections show an intra-articular free fragment (black arrow), the posterior wall fracture (white arrowhead), and an additional vertical fracture line through the quadrilateral plate (black arrowhead), which does not propagate through the obturator ring (white arrow shows intact ring). C: Three-dimensional computed tomography scan shows the main transverse fracture line, posterior wall fragments (white arrowhead), and intra-articular free fragment (white arrow). However, the vertical (incomplete “T” component) is not apparent. D: Drawing of the fracture as part of preoperative planning.
 
(A. From Moed BR. Acetabular fractures: The Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:688. B–D. Copyright Berton R. Moed, MD.)
A: Anteroposterior and oblique radiographs show a juxtatectal transverse acetabular fracture with an associated posterior wall fracture. B: Selected axial computed tomography sections show an intra-articular free fragment (black arrow), the posterior wall fracture (white arrowhead), and an additional vertical fracture line through the quadrilateral plate (black arrowhead), which does not propagate through the obturator ring (white arrow shows intact ring). C: Three-dimensional computed tomography scan shows the main transverse fracture line, posterior wall fragments (white arrowhead), and intra-articular free fragment (white arrow). However, the vertical (incomplete “T” component) is not apparent. D: Drawing of the fracture as part of preoperative planning.
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Figure 47-41
A: Anteroposterior and oblique radiographs show a juxtatectal transverse acetabular fracture with an associated posterior wall fracture. B: Selected axial computed tomography sections show an intra-articular free fragment (black arrow), the posterior wall fracture (white arrowhead), and an additional vertical fracture line through the quadrilateral plate (black arrowhead), which does not propagate through the obturator ring (white arrow shows intact ring). C: Three-dimensional computed tomography scan shows the main transverse fracture line, posterior wall fragments (white arrowhead), and intra-articular free fragment (white arrow). However, the vertical (incomplete “T” component) is not apparent. D: Drawing of the fracture as part of preoperative planning.
(A. From Moed BR. Acetabular fractures: The Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. Philadelphia, PA: Lippincott Williams & Wilkins; 2006:688. B–D. Copyright Berton R. Moed, MD.)
A: Anteroposterior and oblique radiographs show a juxtatectal transverse acetabular fracture with an associated posterior wall fracture. B: Selected axial computed tomography sections show an intra-articular free fragment (black arrow), the posterior wall fracture (white arrowhead), and an additional vertical fracture line through the quadrilateral plate (black arrowhead), which does not propagate through the obturator ring (white arrow shows intact ring). C: Three-dimensional computed tomography scan shows the main transverse fracture line, posterior wall fragments (white arrowhead), and intra-articular free fragment (white arrow). However, the vertical (incomplete “T” component) is not apparent. D: Drawing of the fracture as part of preoperative planning.
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Only by understanding the location and orientation of each fracture line can the fracture pattern be truly appreciated. The authors’ method is as follows. First, the lines on the AP radiograph (Fig. 47-9A) should be carefully analyzed in turn. Is the iliopectineal line disrupted? If so, the fracture possibilities include the anterior wall, anterior column, transverse types, T-shaped, anterior column with posterior hemitransverse, and both-column. If the ilioischial line is disrupted, possibilities include the posterior column types, transverse types, T-shaped, anterior column with posterior hemitransverse, and both-column. With both lines disrupted, the possibilities are reduced to transverse types, T-shaped, anterior column with posterior hemitransverse, and both-column. Is the line along the posterior rim disrupted? If so, this will add the possibility of a posterior wall fracture. Is the ilioischial line displaced from its normal relationship to the teardrop? If so, this would indicate, in general, that the two columns are separated from each other. Next, the obturator oblique is examined (Fig. 47-9C). This view will refine the diagnosis made from the AP view. A suspected posterior wall component will become obvious, as well as disruption involving the anterior wall or column. Is the obturator ring fractured? If so, this, again, would suggest that the two columns are separated from each other. The presence of a spur sign (Fig. 47-31) is pathognomonic for a both-column fracture. The iliac oblique is viewed next (Fig. 47-9B). Injury to the posterior column is further defined, as well as the presence and location of fractures involving the iliac wing (e.g., anterior column, anterior column plus posterior hemitransverse, and both-column fractures). Finally, the CT scan is studied to reveal the additional information described previously. After this analysis, the plain films should be revisited to refine the diagnosis for fracture subtypes (e.g., the level of transverse fracture or the path of the stem of the T-shaped fracture). If the diagnosis continues to be unclear, the three-dimensional CT scan can prove helpful (Fig. 47-41). 
Timing of Acetabular Fracture Surgery.
In general, the surgical treatment of an acetabular fracture is not an emergency. A delay of 3 to 5 days is commonly used to allow for evaluation of any underlying medical problems or associated injuries and for preoperative planning. In addition, it has been generally thought that surgery within the first 24 hours after injury places the patient at risk for increased blood loss. However, recent study indicates that posterior wall fractures can be treated immediately without increased risk of excessive blood loss.47 Regardless, undue delay in the time to surgery has been shown to be a significant predictor of radiologic and clinical outcome.93,100 
Much of the intraoperative maneuvering for acetabular fracture reduction is performed indirectly, without direct exposure or complete visualization of the fracture fragments. These techniques rely on the presence of relatively mobile fracture fragments. Ten days following injury, early fracture healing begins to limit this type of fracture mobilization. Two weeks following injury, healing has often progressed to the point that this fracture mobility has been lost and a more extensive surgical approach is required for certain fracture types, such as the transverse, T-shaped, anterior column with posterior hemitransverse, and both-column patterns.93 After 3 weeks, callus formation is extensive to the point that the fracture is no longer considered to be an acute injury.93 Previous data has indicated that delay in surgical treatment beyond 3 weeks is associated with compromised outcome.37,77,93 More recently, it has been shown that a good-to-excellent clinical outcome is more likely when surgery was performed within 10 to 15 days.100 This compromised outcome is probably related to many factors beyond the more extensive surgical exposure with its attendant higher complication rate, such as acetabular cartilage damage and femoral head erosion.38,77 In any case, the time to surgery has been shown to be a significant predictor of radiologic and clinical outcome and, if possible, should not be delayed beyond 15 days for elementary fractures and 10 days for associated types.100 Indications for emergency operative treatment are uncommon (Table 47-6). Situations that demand emergency surgery include persistent instability following reduction that cannot be controlled by traction and irreducible hip dislocations. Progressive sciatic nerve deficit following acetabular fracture or closed reduction of a dislocated hip is also an indication for emergency surgery despite the fact that the return of nerve function is variable.76,114,133,181 
 
Table 47-6
Indications for Emergency Acetabular Fracture Fixation
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Table 47-6
Indications for Emergency Acetabular Fracture Fixation
Recurrent hip dislocation following reduction despite traction
Irreducible hip dislocation
Progressive sciatic nerve deficit following fracture or closed reduction
Associated vascular injury requiring repair
Open fractures
Ipsilateral femoral neck fracture
X
Selection of the Surgical Approach.
Selection of the appropriate surgical approach is one of the most important aspects of the preoperative planning for acetabular fracture surgery (Table 47-7). The main determinants in the decision-making process are the fracture type, the elapsed time from injury to operative intervention, and the magnitude and location of maximal fracture displacement. A single surgical approach is generally selected with the expectation that the fracture reduction and fixation can be completely performed through the one approach.73,93,94,109 The mainstay surgical approaches to the acetabulum are those described by Letournel and Judet93: The Kocher–Langenbeck, the ilioinguinal, the iliofemoral, and the extended iliofemoral. The first three provide direct access to only one column of the acetabulum (posterior for the Kocher–Langenbeck; anterior for the ilioinguinal and iliofemoral) and rely on indirect manipulation for reduction of any fracture lines that traverse the opposite column. A sequential anterior or posterior approach is then added if the single approach proves insufficient to accomplish a satisfactory indirect reduction of the opposite column.93,107 The extended iliofemoral approach affords the opportunity for almost complete direct access to all aspects of the acetabulum. It is most often used for delayed treatment of an associated fracture type in which fracture healing precludes indirect manipulation. However, alternative approaches have been proposed that may offer important advantages over these standard methods. These include the modified Gibson approach, the trochanteric flip osteotomy, the modified Stoppa approach, and a simultaneous (rather than sequential) combination of the standard anterior and posterior approaches.32,41,66,135,155,163 
 
Table 47-7
Standard Surgical Approaches for Each Fracture Pattern
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Table 47-7
Standard Surgical Approaches for Each Fracture Pattern
Fracture Type Kocher–Langenbeck Ilioinguinal Iliofemoral Sequential Combined Extended Iliofemoral
Elementary
Posterior wall X
Posterior column X
Anterior wall X X
Anterior column X X
Transverse infratectal/juxtatectal X X
Transverse transtectal X X X
Associated
Posterior column and wall X
Anterior and posterior hemitransverse X X X
Transverse infratectal/juxtatectal and post wall X
Transverse transtectal and post wall X X
T-shaped infratectal/juxtatectal X X X
T-shaped transtectal X X
Both-column X X X
 

NOTE: “X” in bold denotes a preferred approach.

X
Patient Positioning for Acetabular Fractures.
Patient position for acetabular fracture surgery is dictated by the fracture type, the particular characteristics of the individual fracture, and the selected surgical approach. Patient positioning is clear cut for three of the four standard surgical approaches: Supine for the iliofemoral and ilioinguinal, and lateral for the extended iliofemoral. However, for the Kocher–Langenbeck approach the patient can be placed in either the prone or lateral position. Surgeons expert in acetabular fracture treatment have specified that the full extent of the Kocher–Langenbeck approach can only be realized by using prone patient positioning.52,93,107 Nonetheless, retrospective studies comparing the two positions have been unable to unequivocally determine that patient position alone has much effect on surgical outcome.33,139 Intraoperative traction is very important in obtaining fracture reduction. Traction not only unloads the hip joint to allow better joint visualization and facilitate direct manipulation of the displaced fracture fragments but also can be used to effect at least a partial reduction of the displaced columns. Traction may often need to be steady and prolonged. For these reasons, traction through a table is preferred to manual methods. Therefore, a purpose-specific traction table, such as a Judet-type fracture table (Fig. 47-42), is very helpful and preferred by many fracture surgeons.93,107,132 Although the Tasserit table is no longer available in North America as a new item, refurbished models are still available (Medrecon, Inc., Garwood, NJ). In any case, if one of these purpose-specific traction tables is not available, an AO/ASIF femoral distractor (Fig. 47-43), or manual traction delivered via a T-handle chuck attached to a Schanz screw placed in the greater trochanter, can be used to provide the intraoperative traction in combination with a standard radiolucent operating room table, such as the Jackson table (Mizuho OSI, Union City, CA). If a T-handle chuck attached to a trochanteric Schanz screw is used, continuous table traction can be improvised by hanging 4.53 to 9.07 kg (10 to 20 lb) of weight off the end of a standard radiolucent OR table. This weight is attached via pulleys and a sterile rope to the T-handle chuck. High-quality intraoperative C-arm fluoroscopy can then be used to assess fracture reduction and hardware location, allowing the surgeon to check the extra-articular location of fixation close to the articular surface as well as to check portions of the articular reduction that are not directly visualized.29,133,140 
Figure 47-42
The Judet fracture table.
 
A small pad can be used to elevate the patient’s head A: A detailed view (B) shows the padded perineal post and the padded support with perineal cutout for male patients. The separation between the chest and the padded perineal support serves to reduce abdominal pressure without requiring additional padding or chest rolls.
 
(From: Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868.) C: The currently available PROfx Fracture Table version manufactured by Mizuho OSI (Figure courtesy of Mizuho OSI, Union City, CA; permission granted).
A small pad can be used to elevate the patient’s head A: A detailed view (B) shows the padded perineal post and the padded support with perineal cutout for male patients. The separation between the chest and the padded perineal support serves to reduce abdominal pressure without requiring additional padding or chest rolls.
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Figure 47-42
The Judet fracture table.
A small pad can be used to elevate the patient’s head A: A detailed view (B) shows the padded perineal post and the padded support with perineal cutout for male patients. The separation between the chest and the padded perineal support serves to reduce abdominal pressure without requiring additional padding or chest rolls.
(From: Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868.) C: The currently available PROfx Fracture Table version manufactured by Mizuho OSI (Figure courtesy of Mizuho OSI, Union City, CA; permission granted).
A small pad can be used to elevate the patient’s head A: A detailed view (B) shows the padded perineal post and the padded support with perineal cutout for male patients. The separation between the chest and the padded perineal support serves to reduce abdominal pressure without requiring additional padding or chest rolls.
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Figure 47-43
The application of a universal distractor, shown on a plastic bone model.
 
(Copyright Berton R. Moed, MD, St. Louis, MO, and Mark S. Vrahas, MD, Boston, MA.)
(Copyright Berton R. Moed, MD, St. Louis, MO, and Mark S. Vrahas, MD, Boston, MA.)
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Figure 47-43
The application of a universal distractor, shown on a plastic bone model.
(Copyright Berton R. Moed, MD, St. Louis, MO, and Mark S. Vrahas, MD, Boston, MA.)
(Copyright Berton R. Moed, MD, St. Louis, MO, and Mark S. Vrahas, MD, Boston, MA.)
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Fracture Reduction and Fixation of Acetabular Fractures.
With the exception of the both-column fracture, the standard fracture reduction sequence is to first reduce and stabilize the displaced columns, if present, and then reduce any wall fracture that may be present. After definitive fixation of the reduced fragments, the entire construct is stabilized with buttress plates. For the both-column fracture (which may have a posterior superior wall fracture component) (Figs. 47-31 and 47-32), the sequence is to first reduce and stabilize one of the columns to the axial skeleton (iliac wing), then the other column, and then, if present, the wall component. After definitive fixation of the reduced fragments, the entire construct is stabilized with buttress plates. Although columns may be stabilized in young, healthy bone using screws alone, osteopenic bone and all wall fractures require buttress plating. Standard fracture fixation constructs exist (Fig. 47-44). However, these often must be modified to accommodate the individual fracture morphology, as determined during preoperative planning. 
Figure 47-44
Schematic diagrams showing the 10 acetabular fracture types, with typical fixation constructs.
 
(A to E show elementary types; F through K show associated types.) A: Multifragmented posterior wall fracture with intra-articular comminution. B: Posterior column fracture. C: Anterior wall fracture. D: High anterior column fracture. E: Juxtatectal transverse fracture. F: Posterior column and posterior wall fracture. G: Transverse and posterior wall fracture. H: T-shaped fracture. I: Anterior column and posterior hemitransverse fracture. J: Both-column fracture; the ilioinguinal approach was used. K: Both-column fracture with posterior column comminution; the extended iliofemoral approach was used.
 
(Copyright Berton R. Moed, MD, St. Louis, MO.)
(A to E show elementary types; F through K show associated types.) A: Multifragmented posterior wall fracture with intra-articular comminution. B: Posterior column fracture. C: Anterior wall fracture. D: High anterior column fracture. E: Juxtatectal transverse fracture. F: Posterior column and posterior wall fracture. G: Transverse and posterior wall fracture. H: T-shaped fracture. I: Anterior column and posterior hemitransverse fracture. J: Both-column fracture; the ilioinguinal approach was used. K: Both-column fracture with posterior column comminution; the extended iliofemoral approach was used.
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Figure 47-44
Schematic diagrams showing the 10 acetabular fracture types, with typical fixation constructs.
(A to E show elementary types; F through K show associated types.) A: Multifragmented posterior wall fracture with intra-articular comminution. B: Posterior column fracture. C: Anterior wall fracture. D: High anterior column fracture. E: Juxtatectal transverse fracture. F: Posterior column and posterior wall fracture. G: Transverse and posterior wall fracture. H: T-shaped fracture. I: Anterior column and posterior hemitransverse fracture. J: Both-column fracture; the ilioinguinal approach was used. K: Both-column fracture with posterior column comminution; the extended iliofemoral approach was used.
(Copyright Berton R. Moed, MD, St. Louis, MO.)
(A to E show elementary types; F through K show associated types.) A: Multifragmented posterior wall fracture with intra-articular comminution. B: Posterior column fracture. C: Anterior wall fracture. D: High anterior column fracture. E: Juxtatectal transverse fracture. F: Posterior column and posterior wall fracture. G: Transverse and posterior wall fracture. H: T-shaped fracture. I: Anterior column and posterior hemitransverse fracture. J: Both-column fracture; the ilioinguinal approach was used. K: Both-column fracture with posterior column comminution; the extended iliofemoral approach was used.
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General Instrumentation for Acetabular Fractures.
An extensive array of special instruments is required (Fig. 47-45). An oscillating drill is helpful for placing screws deep within the wound. The implants of choice are 3.5-mm reconstruction-type plates, either curved or straight, that can be contoured intraoperatively to match the complex three-dimensional shape of the innominate bone. Cortical screws of 3.5- and 4.5-mm diameter should be available in lengths at least up to 100 mm. Longer or smaller diameter (2.7- or 2-mm) screws may be required, depending on the fracture configuration or comminution. Locked plating has been advocated for use in many areas of the skeletal system, and biomechanical study in a transverse acetabular fracture model has shown this construct to be as strong as conventional plating in combination with an interfragmentary screw.116 However, clinical evidence for its advantages in acetabular fracture surgery remains limited. 
Figure 47-45
Examples of available instruments for acetabular fracture reduction.
 
A: Special offset clamps that permit intrapelvic and anterior column access. B: Other useful reduction clamps, from left to right: Large reduction forceps with points; pelvic reduction clamp (Jungbluth reduction clamp); large pelvic reduction forceps with pointed ball tips; straight ball-spiked pusher; Farabeuf reduction forceps; and serrated reduction forceps.
 
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868.)
A: Special offset clamps that permit intrapelvic and anterior column access. B: Other useful reduction clamps, from left to right: Large reduction forceps with points; pelvic reduction clamp (Jungbluth reduction clamp); large pelvic reduction forceps with pointed ball tips; straight ball-spiked pusher; Farabeuf reduction forceps; and serrated reduction forceps.
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Figure 47-45
Examples of available instruments for acetabular fracture reduction.
A: Special offset clamps that permit intrapelvic and anterior column access. B: Other useful reduction clamps, from left to right: Large reduction forceps with points; pelvic reduction clamp (Jungbluth reduction clamp); large pelvic reduction forceps with pointed ball tips; straight ball-spiked pusher; Farabeuf reduction forceps; and serrated reduction forceps.
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868.)
A: Special offset clamps that permit intrapelvic and anterior column access. B: Other useful reduction clamps, from left to right: Large reduction forceps with points; pelvic reduction clamp (Jungbluth reduction clamp); large pelvic reduction forceps with pointed ball tips; straight ball-spiked pusher; Farabeuf reduction forceps; and serrated reduction forceps.
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Standard Surgical Approaches for Acetabular Fractures.
The Kocher–Langenbeck Approach
The Kocher–Langenbeck Approach is ideal for posterior wall fractures and posterior column fractures with or without an associated posterior wall fracture (Fig. 47-46). Transverse and T-shaped fractures, treated within 15 days of injury, are also amenable to this surgical approach. In addition, for T-shaped fractures, the major displacement should be posterior, with only minor displacement occurring anteriorly at the pelvic brim (Table 47-7). The Kocher–Langenbeck approach provides direct visualization of the entire lateral aspect of the posterior column of the acetabulum (Fig. 47-47). The greater and lesser sciatic notches are visualized by transecting the piriformis and obturator internus tendons and dissecting subperiosteally into the notches. The most caudal portion of the ilium is accessible but the superior gluteal neurovascular bundle limits proximal exposure. Visualization may be extended anterosuperiorly by dividing a portion of the gluteus medius insertion or performing a transtrochanteric osteotomy, but proximal access is still largely limited. Indirect access to the quadrilateral surface can be attained by the palpating finger or the use of special instruments placed through the greater sciatic notch. A posterior capsulotomy allows limited access to the posterior aspect of the joint surface. This access is increased without the need for a capsulotomy in the presence of a fractured posterior wall. 
Figure 47-46
The Kocher–Langenbeck approach.
 
A: The skin incision. B: The fascia lata and gluteus maximus have been split. The short external rotators are seen with the sciatic nerve lying on the dorsal surface of the quadratus femoris. The gluteus maximus tendon has been transected. C: The retroacetabular surface is exposed by transecting the tendons of the piriformis and obturator internus and reflecting them back toward the sciatic notches.
 
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868.)
A: The skin incision. B: The fascia lata and gluteus maximus have been split. The short external rotators are seen with the sciatic nerve lying on the dorsal surface of the quadratus femoris. The gluteus maximus tendon has been transected. C: The retroacetabular surface is exposed by transecting the tendons of the piriformis and obturator internus and reflecting them back toward the sciatic notches.
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Figure 47-46
The Kocher–Langenbeck approach.
A: The skin incision. B: The fascia lata and gluteus maximus have been split. The short external rotators are seen with the sciatic nerve lying on the dorsal surface of the quadratus femoris. The gluteus maximus tendon has been transected. C: The retroacetabular surface is exposed by transecting the tendons of the piriformis and obturator internus and reflecting them back toward the sciatic notches.
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868.)
A: The skin incision. B: The fascia lata and gluteus maximus have been split. The short external rotators are seen with the sciatic nerve lying on the dorsal surface of the quadratus femoris. The gluteus maximus tendon has been transected. C: The retroacetabular surface is exposed by transecting the tendons of the piriformis and obturator internus and reflecting them back toward the sciatic notches.
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Figure 47-47
Access provided by the Kocher–Langenbeck approach.
 
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the quadratus femoris muscle. (Copyright Berton R. Moed, MD.)
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the quadratus femoris muscle. (Copyright Berton R. Moed, MD.)
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Figure 47-47
Access provided by the Kocher–Langenbeck approach.
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the quadratus femoris muscle. (Copyright Berton R. Moed, MD.)
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the quadratus femoris muscle. (Copyright Berton R. Moed, MD.)
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The skin incision is centered over the greater trochanter (Fig. 47-46A). The proximal branch of the incision is directed toward the posterior superior iliac spine, ending approximately 6 cm short of this bony landmark. Distally, the incision extends approximately 15 cm along the midlateral aspect of the thigh. The fascia lata is sharply incised and the gluteus maximus muscle is bluntly divided toward the posterior superior iliac spine (Fig. 47-46B). The innervation of the gluteus maximus muscle comes from the inferior gluteal nerve, which runs from posterior to anterior in the muscle. Therefore, the splitting of this muscle should stop as soon as the first nerve trunk is met, approximately at the midpoint between the greater trochanter and the posterior superior iliac spine (Fig. 47-48).93 Otherwise, the muscle fibers anterior to the dissection will be deinnervated. Next, the insertion of the gluteus maximus muscle into the femur is released (Fig. 47-46B). This allows posteromedial retraction of the muscle without excessive stretch on the inferior gluteal nerve. The sciatic nerve is then located along the posterior surface of the quadratus femoris muscle and traced proximally to the piriformis muscle. The short external rotators and piriformis tendon are divided and tagged with sutures to assist with retraction (Fig. 47-46C). Gentle retraction of the short external rotators allows visualization of the posterior column and retroacetabular space, but provides only limited protection of the sciatic nerve. 
Figure 47-48
 
A: Gluteus maximus muscle fibers are split to the first nerve branch. A self-retaining retractor holds the gluteus maximus muscle fibers apart. The nerve (located at the tip of the scissors) is crossing the split in the gluteus maximus muscle fibers from posterior to anterior in the surgical field. B: Companion drawing to clarify the technique in (A).
 
(Figure A copyright Berton R. Moed, MD.) (Figure B From Moed BR. Acetabular fractures: Kocher -Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868.)
A: Gluteus maximus muscle fibers are split to the first nerve branch. A self-retaining retractor holds the gluteus maximus muscle fibers apart. The nerve (located at the tip of the scissors) is crossing the split in the gluteus maximus muscle fibers from posterior to anterior in the surgical field. B: Companion drawing to clarify the technique in (A).
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Figure 47-48
A: Gluteus maximus muscle fibers are split to the first nerve branch. A self-retaining retractor holds the gluteus maximus muscle fibers apart. The nerve (located at the tip of the scissors) is crossing the split in the gluteus maximus muscle fibers from posterior to anterior in the surgical field. B: Companion drawing to clarify the technique in (A).
(Figure A copyright Berton R. Moed, MD.) (Figure B From Moed BR. Acetabular fractures: Kocher -Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868.)
A: Gluteus maximus muscle fibers are split to the first nerve branch. A self-retaining retractor holds the gluteus maximus muscle fibers apart. The nerve (located at the tip of the scissors) is crossing the split in the gluteus maximus muscle fibers from posterior to anterior in the surgical field. B: Companion drawing to clarify the technique in (A).
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After the obturator internus tendon is released from its insertion into the greater trochanter and is elevated away from the hip capsule (along with the gemelli muscles) and followed medially toward the lesser sciatic notch, the underlying bursa is opened, permitting access to (and palpation through) the lesser sciatic notch. A specially designed sciatic nerve retractor can now be placed with its tip anchored in the lesser sciatic notch (Fig. 47-49). Use of this instrument facilitates the bony exposure by permitting controlled retraction of the sciatic nerve and the posterior soft tissues. The retractor is positioned such that at the level of the lesser sciatic notch, the obturator internus tendons and gemelli muscles lie between the retractor and the sciatic nerve, cushioning the nerve. However, the surgeon must realize that the sciatic nerve retractor extends beyond the limits of this muscle cushion and directly contacts the nerve at the superior and inferior aspects of the retractor. The relation between the sciatic nerve and the sciatic nerve retractor must be such that the edges of the retractor do not impinge or place undue pressure on the nerve. 
Figure 47-49
Bone model showing the sciatic nerve retractor (inset) positioned in the lesser sciatic notch.
 
(From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum: Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107, with permission.)
(From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum: Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107, with permission.)
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Figure 47-49
Bone model showing the sciatic nerve retractor (inset) positioned in the lesser sciatic notch.
(From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum: Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107, with permission.)
(From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum: Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107, with permission.)
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Although surgeons are familiar with the posterior approach to the hip, there are special considerations when exposing an acetabular fracture. Transecting the piriformis and obturator internus tendons must be performed at least 1.5 cm from the greater trochanter to avoid injury to the ascending branch of the medial femoral circumflex artery.71 Dissection caudal to the inferior gemellus on the femur must be avoided, also to preserve the blood supply to the femoral head (Fig. 47-35). If more distal exposure of the ischium is necessary, elevation of the quadratus femoris muscle can be performed from its ischial attachment rather than its femoral side. Excessive superior and lateral retraction of the abductors can place harmful tension on the superior gluteal neurovascular bundle. If additional superior and anterior exposure is required, to secure buttress plate fixation for a superiorly located posterior wall fracture for instance, anterior extension of the exposure can be accomplished without excessive traction on the abductors or superior gluteal neurovascular pedicle by using a standard or a flip osteotomy of the greater trochanter (see Alternative Approaches section).20,41,163 As opposed to the situation for posterior approaches to the hip for total hip arthroplasty, during acetabular fracture surgery the sciatic nerve must be directly visualized and protected. Therefore, it is important to recognize the normal potential variability in the relationship between the sciatic nerve and the piriformis muscle. Typically (about 84% of the time), the sciatic nerve runs deep to the piriformis muscle, appearing in the buttock at the inferior border of this muscle.55 Three variations of this “normal” anatomy have been reported, and others probably exist.55 The most common variation (12%) is for one part of the nerve (the peroneal division) to pass through the muscle and the other part (the tibial division) to appear below the muscle. The entire nerve also may pass through the muscle (1%). These two variations result in a split piriformis muscle with two tendons of insertion. The third variation is passage of the peroneal division above the piriformis and the tibial division below it (3%). With enough operative cases, one will eventually encounter one of these anatomic anomalies (Fig. 47-50). Knowledge of the anatomic variability of this area and the prior identification of the sciatic nerve on the posterior surface of the quadratus femoris muscle will prevent intraoperative confusion and decrease the risk of iatrogenic sciatic nerve injury. 
Figure 47-50
Drawing showing a split sciatic nerve with the peroneal division above the piriformis muscle and the tibial division below the piriformis muscle.
 
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868, Fig. 41.33 page 844.)
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868, Fig. 41.33 page 844.)
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Figure 47-50
Drawing showing a split sciatic nerve with the peroneal division above the piriformis muscle and the tibial division below the piriformis muscle.
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868, Fig. 41.33 page 844.)
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012:817–868, Fig. 41.33 page 844.)
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The Ilioinguinal Approach
The ilioinguinal approach is indicated for anterior wall and anterior column fractures, as well as for most anterior column/wall and posterior hemitransverse fractures and most both-column fractures (Table 47-7) (Fig. 47-51). Transverse fractures in which the major displacement is anterior with minimal posterior displacement and both-column fractures having a noncomminuted posterior column fragment can also be managed using this approach. These complex fracture types must not have displacement in the anatomic roof and should be treated within 15 days of injury; otherwise an alternative, more extensive, surgical approach may be required. In general, the ilioinguinal approach is not recommended for both-column fractures with a displaced fracture line involving the sacroiliac joint. However, Weber and Mast190 described improved access to the external aspect of the ilium by positioning the patient in the semilateral position and extending the skin incision to the posterior superior iliac spine. The posterior aspect of the abductor origin and a portion of the gluteus maximus origin are detached from the external aspect of the ilium. If there is a sacroiliac fracture-dislocation component to a both-column fracture, this may be helpful. 
Figure 47-51
The ilioinguinal approach.
 
A: The skin incision extends from just posterior to the gluteus medius tubercle, paralleling the iliac crest to the anterior superior iliac spine, and then coursing medially to the midline ending two finger-breadths above the pubic symphysis. B: The iliacus muscle has been dissected subperiosteally from the internal iliac fossa, and the external oblique aponeurosis has been incised from the anterior superior iliac spine to the midline, passing at least 1 cm superior to the superficial inguinal ring, and reflected distally. The spermatic cord in the male or the round ligament in the female is bluntly isolated along with the ilioinguinal nerve and retracted using a rubber sling. The now-exposed inguinal ligament is split through its entire length and the iliopectineal fascia is seen to be separating the femoral nerve and iliopsoas from the external iliac vessels. C: The iliopectineal fascia has been released and the exposure is complete. The lateral window exposes the internal iliac fossa to the sacroiliac joint and the pelvic brim. D: The middle window exposes the pelvic brim to the pectineal eminence, the quadrilateral surface, and the anterior wall. E: The medial window is shown here with retraction of the spermatic cord laterally. The rectus abdominis tendon has been transected. The space of Retzius, superior ramus, and symphysis pubis are visualized.
A: The skin incision extends from just posterior to the gluteus medius tubercle, paralleling the iliac crest to the anterior superior iliac spine, and then coursing medially to the midline ending two finger-breadths above the pubic symphysis. B: The iliacus muscle has been dissected subperiosteally from the internal iliac fossa, and the external oblique aponeurosis has been incised from the anterior superior iliac spine to the midline, passing at least 1 cm superior to the superficial inguinal ring, and reflected distally. The spermatic cord in the male or the round ligament in the female is bluntly isolated along with the ilioinguinal nerve and retracted using a rubber sling. The now-exposed inguinal ligament is split through its entire length and the iliopectineal fascia is seen to be separating the femoral nerve and iliopsoas from the external iliac vessels. C: The iliopectineal fascia has been released and the exposure is complete. The lateral window exposes the internal iliac fossa to the sacroiliac joint and the pelvic brim. D: The middle window exposes the pelvic brim to the pectineal eminence, the quadrilateral surface, and the anterior wall. E: The medial window is shown here with retraction of the spermatic cord laterally. The rectus abdominis tendon has been transected. The space of Retzius, superior ramus, and symphysis pubis are visualized.
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Figure 47-51
The ilioinguinal approach.
A: The skin incision extends from just posterior to the gluteus medius tubercle, paralleling the iliac crest to the anterior superior iliac spine, and then coursing medially to the midline ending two finger-breadths above the pubic symphysis. B: The iliacus muscle has been dissected subperiosteally from the internal iliac fossa, and the external oblique aponeurosis has been incised from the anterior superior iliac spine to the midline, passing at least 1 cm superior to the superficial inguinal ring, and reflected distally. The spermatic cord in the male or the round ligament in the female is bluntly isolated along with the ilioinguinal nerve and retracted using a rubber sling. The now-exposed inguinal ligament is split through its entire length and the iliopectineal fascia is seen to be separating the femoral nerve and iliopsoas from the external iliac vessels. C: The iliopectineal fascia has been released and the exposure is complete. The lateral window exposes the internal iliac fossa to the sacroiliac joint and the pelvic brim. D: The middle window exposes the pelvic brim to the pectineal eminence, the quadrilateral surface, and the anterior wall. E: The medial window is shown here with retraction of the spermatic cord laterally. The rectus abdominis tendon has been transected. The space of Retzius, superior ramus, and symphysis pubis are visualized.
A: The skin incision extends from just posterior to the gluteus medius tubercle, paralleling the iliac crest to the anterior superior iliac spine, and then coursing medially to the midline ending two finger-breadths above the pubic symphysis. B: The iliacus muscle has been dissected subperiosteally from the internal iliac fossa, and the external oblique aponeurosis has been incised from the anterior superior iliac spine to the midline, passing at least 1 cm superior to the superficial inguinal ring, and reflected distally. The spermatic cord in the male or the round ligament in the female is bluntly isolated along with the ilioinguinal nerve and retracted using a rubber sling. The now-exposed inguinal ligament is split through its entire length and the iliopectineal fascia is seen to be separating the femoral nerve and iliopsoas from the external iliac vessels. C: The iliopectineal fascia has been released and the exposure is complete. The lateral window exposes the internal iliac fossa to the sacroiliac joint and the pelvic brim. D: The middle window exposes the pelvic brim to the pectineal eminence, the quadrilateral surface, and the anterior wall. E: The medial window is shown here with retraction of the spermatic cord laterally. The rectus abdominis tendon has been transected. The space of Retzius, superior ramus, and symphysis pubis are visualized.
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The ilioinguinal approach allows access to the internal aspect of the innominate bone from the sacroiliac joint to the symphysis pubis (Fig. 47-52). Direct visualization of the internal iliac fossa, pelvic brim, superior pubic ramus, and a portion of the quadrilateral surface is achieved. Indirect access to the inferior portion of the quadrilateral surface can be attained by the palpating finger or the use of special instruments. Limited access to the external aspect of the iliac wing is possible by release of the abductor origin. This approach does not allow direct access to the hip joint. Fractures requiring direct visualization for removal of intra-articular debris or fracture fixation may require a distal extension in the plane between the sartorius and tensor fascia lata muscle distal to the inguinal ligament, as in the iliofemoral approach (see below).85 The exposure of the quadrilateral surface obtained through the modified Stoppa approach (see below) can also be attained with ilioinguinal approach by extending the incision medially across the midline and having the operating surgeon repositioned on the side of the OR table opposite to the fracture and work through the medial window.82,151 The locations where fixation screws can be placed along the pelvic brim to avoid intra-articular compromise have been generally determined.93 More recently, a safe zone has been identified to assist in avoiding intra-articular screw placement which is based on preoperative CT measurements of the femoral head diameter and intersacroiliac joint distance referenced as anthropometric parameters.59 The clinical effectiveness of this technique remains to be seen. 
Figure 47-52
Access provided by the ilioinguinal approach.
 
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the tensor fasciae latae muscle.
 
(Copyright Berton R. Moed, MD. Permission granted for nonexclusive unrestricted use.)
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the tensor fasciae latae muscle.
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Figure 47-52
Access provided by the ilioinguinal approach.
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the tensor fasciae latae muscle.
(Copyright Berton R. Moed, MD. Permission granted for nonexclusive unrestricted use.)
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the tensor fasciae latae muscle.
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With the patient in the supine position, the skin incision extends from just posterior to the gluteus medius tubercle, paralleling the iliac crest to the anterior superior iliac spine and then coursing medially to the midline ending two fingerbreadths above the pubic symphysis (Fig. 47-51).105 The iliacus muscle is elevated from the internal iliac fossa. The aponeurosis of the external oblique muscle (along with the anterior aspect of the sheath of the rectus abdominis) is then incised from the anterior superior iliac spine to the midline, passing at least 1 cm superior to the superficial inguinal ring. The aponeurosis is reflected distally revealing the spermatic cord in the male and the round ligament in the female. This structure is bluntly isolated along with the ilioinguinal nerve and retracted using a rubber sling. The now exposed inguinal ligament is split through its entire length, revealing the laterally located lacuna musculorum contents (lateral femoral cutaneous nerve, the iliopsoas muscle mass, and femoral nerve) and the medially located lacuna vasorum containing the external iliac vessels and lymphatics.93 The iliopectineal fascia, which separates these lacunae, must be incised to allow access to the quadrilateral plate and true pelvis. Separate rubber slings are placed around the lacuna musculorum contents and the external iliac vessels. In this way, three surgical access “windows” are created. 
The lateral window (exposed by the subperiosteal elevation of the iliacus muscle from the internal iliac fossa) allows exposure of the iliac crest and the internal iliac fossa medially to the sacroiliac joint and distally to the pelvic brim. The middle window (created by the release of the iliopectineal fascia and retraction of the iliopsoas and femoral nerve laterally and the external iliac artery and vein medially) allows exposure of the anterior wall, pectineal eminence, pelvic brim, and quadrilateral surface. Prior to retraction of the vessels, care must be taken to look for an anomalous origin of the obturator artery, known as the corona mortis, or other anastomoses between the obturator and the external iliac systems (Fig. 47-53).54 The medial window, created by lateral retraction of the vessels with either medial or lateral retraction of the spermatic cord (or round ligament), provides exposure to the superior pubic ramus and pubic symphysis. The ipsilateral rectus abdominis tendon may be transected to allow additional access to the space of Retzius (retropubic space) and exposure to the pubic symphysis. 
Figure 47-53
 
A: Illustration of the commonly occurring small-caliber anastomoses between the obturator and external iliac systems. B: Illustration of the true “corona mortis” aberrant origin of the obturator artery from the external iliac system.
A: Illustration of the commonly occurring small-caliber anastomoses between the obturator and external iliac systems. B: Illustration of the true “corona mortis” aberrant origin of the obturator artery from the external iliac system.
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Figure 47-53
A: Illustration of the commonly occurring small-caliber anastomoses between the obturator and external iliac systems. B: Illustration of the true “corona mortis” aberrant origin of the obturator artery from the external iliac system.
A: Illustration of the commonly occurring small-caliber anastomoses between the obturator and external iliac systems. B: Illustration of the true “corona mortis” aberrant origin of the obturator artery from the external iliac system.
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With this approach, the lateral femoral cutaneous nerve, the femoral nerve, the external iliac vessels, and the inguinal canal contents are all at risk for injury. The lateral femoral cutaneous nerve must be identified and protected throughout the procedure. While working within the middle window, the pulse in the external iliac artery should be frequently checked as thrombosis or intimal injury may occur with prolonged tension on the artery. Despite the fact that the approach is anterior, the sciatic nerve can be injured by stretch from a combination of poor patient positioning and excessive traction or by direct injury from a wayward posteriorly directed drill bit or screw. 
The Iliofemoral Approach
The iliofemoral approach is a standard approach that has limited applications (Fig. 47-54). Although the ilioinguinal is usually the better choice, the iliofemoral approach may be sufficient for high anterior column fractures in which the main displacement is cephalad to the hip joint (Table 47-7). The iliofemoral approach and the approach named after Smith-Peterson share a similar skin incision but differ markedly. The iliofemoral is directed to intrapelvic exposure (Figs. 47-54 and 47-55); the Smith-Peterson incision exposes the hip joint anteriorly. This approach provides direct access to the iliac crest and the entire internal iliac fossa but does not allow access medial to the iliopectineal eminence (Fig. 47-55).93 Rather than using a fracture table, the supine position on a standard radiolucent OR table is preferred, as the medial limit of the exposure extends to the iliopectineal eminence when the ipsilateral limb is prepped free and the hip can be flexed to 60 to 90 degrees and adducted. There is limited indirect access to the true pelvis, with a finger or an instrument, as far as the superior aspect of the quadrilateral plate. The anterior wall fracture that is the morphologic equivalent of the isolated posterior wall fracture (Fig. 47-20) is best treated using a modified Smith-Peterson anterior approach, which incorporates the intrapelvic dissection of the iliofemoral approach.92 
Figure 47-54
The iliofemoral approach.
 
A: Skin incision. B: Deep dissection by elevation of muscles of the inner surface of the pelvis and release of the sartorius origin and ilioinguinal ligament. Removal of the muscles of the outer surface of the pelvis, as shown, should be undertaken only if needed and with great care to not devitalize the anterior column fracture fragment.
A: Skin incision. B: Deep dissection by elevation of muscles of the inner surface of the pelvis and release of the sartorius origin and ilioinguinal ligament. Removal of the muscles of the outer surface of the pelvis, as shown, should be undertaken only if needed and with great care to not devitalize the anterior column fracture fragment.
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Figure 47-54
The iliofemoral approach.
A: Skin incision. B: Deep dissection by elevation of muscles of the inner surface of the pelvis and release of the sartorius origin and ilioinguinal ligament. Removal of the muscles of the outer surface of the pelvis, as shown, should be undertaken only if needed and with great care to not devitalize the anterior column fracture fragment.
A: Skin incision. B: Deep dissection by elevation of muscles of the inner surface of the pelvis and release of the sartorius origin and ilioinguinal ligament. Removal of the muscles of the outer surface of the pelvis, as shown, should be undertaken only if needed and with great care to not devitalize the anterior column fracture fragment.
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Figure 47-55
Access provided by the iliofemoral approach.
 
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of approximate indirect access.
 
(Copyright Berton R. Moed, MD. Permission granted for nonexclusive unrestricted use.)
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of approximate indirect access.
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Figure 47-55
Access provided by the iliofemoral approach.
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of approximate indirect access.
(Copyright Berton R. Moed, MD. Permission granted for nonexclusive unrestricted use.)
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of approximate indirect access.
View Original | Slide (.ppt)
X
The incision extends from just posterior to the gluteus medius tubercle, paralleling the iliac crest, to the anterior superior iliac spine and then coursing distally for approximately 15 cm along the lateral aspect of the sartorius muscle (Fig. 47-54). The iliopsoas muscle is elevated off the inner aspect of the iliac crest. The sartorius origin and inguinal ligament are released from the anterior superior iliac spine. The interval between the sartorius and the tensor fascia lata is developed to allow exposure of the anterior hip joint capsule, the anteroinferior iliac spine, and the anterior column as far medial as the iliopectineal eminence. Removal of the muscles of the outer surface of the pelvis should be undertaken only if absolutely required and with great care to not devitalize the anterior column fracture fragment. This approach is fairly simple and of low risk. However, access to the anterior column is quite limited. The lateral femoral cutaneous nerve or some portion thereof is commonly injured with this approach. 
The Extended Iliofemoral Approach
The extended iliofemoral approach is indicated for selected complex acetabular fracture types (Table 47-7) and for surgery delayed more than 2 weeks following injury (see the earlier section on timing of surgery) (Fig. 47-56). These include transverse plus posterior wall fractures if the surgeon expects unusual difficulties with reduction.93,107 Examples of those fractures for which an extended iliofemoral approach is indicated include a transtectal transverse component with an extended posterior wall fracture (involving the posterior border of the bone), a T-shaped and posterior wall fracture, and those associated with dislocation of the symphysis pubis or fracture of the contralateral pubis ramus.105,179 Select T-shaped fractures include those with a transtectal transverse component, those with a wide separation along the vertical stem of the T, and those associated with dislocation of the symphysis pubis or fracture of the contralateral pubic ramus.105,179 Select both-column fractures include those having a complex fracture of the posterior column, a displaced fracture line crossing the sacroiliac joint, or a wide separation of the anterior and posterior columns at the rim of the acetabulum.107 Currently, this approach is most often used for delayed treatment of an associated fracture type in which fracture healing precludes indirect manipulation. 
Figure 47-56
The extended iliofemoral approach.
 
A: The skin incision runs from the posterior superior iliac spine to the anterior spine and then curves to lie on the anterior-lateral thigh. B: The abductors have been reflected subperiosteally from the external ilium and reflected posteriorly with the tensor fascia lata muscle. The fascia separating the tensor from the rectus is split and the ascending branch of the lateral femoral circumflex vessels is ligated. C: The abductor tendons are here transected from the greater trochanter. Alternatively, a trochanteric osteotomy can be performed. D: The piriformis and obturator internus tendons have been transected and the exposure to the external ilium is completed. A capsulotomy is shown.
A: The skin incision runs from the posterior superior iliac spine to the anterior spine and then curves to lie on the anterior-lateral thigh. B: The abductors have been reflected subperiosteally from the external ilium and reflected posteriorly with the tensor fascia lata muscle. The fascia separating the tensor from the rectus is split and the ascending branch of the lateral femoral circumflex vessels is ligated. C: The abductor tendons are here transected from the greater trochanter. Alternatively, a trochanteric osteotomy can be performed. D: The piriformis and obturator internus tendons have been transected and the exposure to the external ilium is completed. A capsulotomy is shown.
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Figure 47-56
The extended iliofemoral approach.
A: The skin incision runs from the posterior superior iliac spine to the anterior spine and then curves to lie on the anterior-lateral thigh. B: The abductors have been reflected subperiosteally from the external ilium and reflected posteriorly with the tensor fascia lata muscle. The fascia separating the tensor from the rectus is split and the ascending branch of the lateral femoral circumflex vessels is ligated. C: The abductor tendons are here transected from the greater trochanter. Alternatively, a trochanteric osteotomy can be performed. D: The piriformis and obturator internus tendons have been transected and the exposure to the external ilium is completed. A capsulotomy is shown.
A: The skin incision runs from the posterior superior iliac spine to the anterior spine and then curves to lie on the anterior-lateral thigh. B: The abductors have been reflected subperiosteally from the external ilium and reflected posteriorly with the tensor fascia lata muscle. The fascia separating the tensor from the rectus is split and the ascending branch of the lateral femoral circumflex vessels is ligated. C: The abductor tendons are here transected from the greater trochanter. Alternatively, a trochanteric osteotomy can be performed. D: The piriformis and obturator internus tendons have been transected and the exposure to the external ilium is completed. A capsulotomy is shown.
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The extended iliofemoral approach was developed by Letournel as a surgical approach to the external aspect of the acetabulum and innominate bone (Fig. 47-57). The approach, derived from the Smith-Petersen approach, provides maximum simultaneous access to both columns of the acetabulum. The entire lateral aspect of the iliac wing, the anterior column to the level of the iliopectineal eminence, the retroacetabular surface, and the interior of the hip joint are accessible. 
Figure 47-57
Access provided by the extended iliofemoral approach.
 
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by elevation of the iliacus from the internal iliac fossa.
 
(Copyright Berton R. Moed, MD.)
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by elevation of the iliacus from the internal iliac fossa.
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Figure 47-57
Access provided by the extended iliofemoral approach.
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by elevation of the iliacus from the internal iliac fossa.
(Copyright Berton R. Moed, MD.)
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by elevation of the iliacus from the internal iliac fossa.
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The patient is placed in the lateral position and the knee maintained in a flexed position to relax the sciatic nerve. An inverted J incision is used, extending from the posterior superior iliac spine along the iliac crest to the anterior superior iliac spine and then continued distally to the midpoint of the thigh angling toward a point 2 cm lateral to the lateral aspect of the patella (Fig. 47-56). The gluteal and tensor fascia lata muscles are elevated from the external surface of the ilium and are hinged on the superior gluteal neurovascular bundle. The hip abductors are released from their insertion into the greater trochanter. Alternatively, the greater trochanter may be osteotomized. Next, the short external rotators are released from their insertion into the greater trochanter to complete the exposure of almost the entire external surface of the bone. Release of the reflected head of the rectus femoris combined with a circumferential capsulotomy at the acetabular rim provides direct visualization of the hip joint. The exposure can be extended medially by release of the sartorius and rectus femoris origins and elevation of the iliacus from the internal iliac fossa. In this way, the extended iliofemoral approach allows almost complete direct access to all aspects of the acetabulum. However, this additional muscle stripping creates added risk of iliac wing and acetabular dome devascularization and increased risk of infection.69 The prevalence of postoperative infection has been reported to be as low as 4%, but as high as 19% using this approach.93,112 
Alternative Surgical Approaches for Acetabular Fractures.
The Trochanteric Flip Osteotomy
The trochanteric flip osteotomy is a variation of the Kocher–Langenbeck approach that is used to attain additional anterosuperior exposure and to facilitate intraoperative dislocation of the femoral head for inspection of the joint (Fig. 47-58).41,163,177 Although the patient is usually in the lateral position for this approach,41 the patient can also be placed in the prone position.127 Indications potentially include combined femoral head–posterior wall acetabular fractures, posterior wall, and column fracture types, as well as certain transverse or T-shaped fractures.163,177 
Figure 47-58
The trochanteric flip osteotomy using a Kocher–Langenbeck approach.
 
A: Exposure without trochanteric osteotomy. B: Exposure of the supra-acetabular area after osteotomy with anterior retraction of the osteotomized trochanter. C: Posterior dislocation of the femoral head, which is facilitated by the trochanteric osteotomy.
 
(Redrawn from Siebenrock KA, Gautier E, Ziran BH, et al. Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture fixation using the Kocher–Langenbeck approach. J Orthop Trauma. 1998;12:387–391.)
A: Exposure without trochanteric osteotomy. B: Exposure of the supra-acetabular area after osteotomy with anterior retraction of the osteotomized trochanter. C: Posterior dislocation of the femoral head, which is facilitated by the trochanteric osteotomy.
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Figure 47-58
The trochanteric flip osteotomy using a Kocher–Langenbeck approach.
A: Exposure without trochanteric osteotomy. B: Exposure of the supra-acetabular area after osteotomy with anterior retraction of the osteotomized trochanter. C: Posterior dislocation of the femoral head, which is facilitated by the trochanteric osteotomy.
(Redrawn from Siebenrock KA, Gautier E, Ziran BH, et al. Trochanteric flip osteotomy for cranial extension and muscle protection in acetabular fracture fixation using the Kocher–Langenbeck approach. J Orthop Trauma. 1998;12:387–391.)
A: Exposure without trochanteric osteotomy. B: Exposure of the supra-acetabular area after osteotomy with anterior retraction of the osteotomized trochanter. C: Posterior dislocation of the femoral head, which is facilitated by the trochanteric osteotomy.
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This osteotomy splits the ridge on the posterior aspect of the greater trochanter and exits anteriorly just medial to the gluteus medius and minimus insertions (Fig. 47-58). Some fibers of the gluteus minimus tendon are transected from the anterior trochanter, but the majority of the tendon insertion remains with the trochanteric fragment. This is also referred to as a digastric osteotomy because both the abductor and vastus lateralis insertions remain on the trochanteric fragment. The insertion of the piriformis tendon remains on the intact proximal femur. This protects the blood supply to the femoral head from the ascending branch of the medial femoral circumflex artery. Anterior exposure is then facilitated by retraction of the trochanteric fragment anteriorly. Cranial exposure is still limited by the superior gluteal neurovascular bundle, and if more cranial exposure of the posterior iliac wing is thought to be necessary, an extended approach should be chosen primarily. 
Modified Gibson Approach
The modified Gibson approach differs from the Kocher–Langenbeck approach in its proximal dissection (Fig. 47-59). The interval between the gluteus maximus and tensor fasciae lata muscles is developed, rather than splitting the gluteus maximus muscle.126,135 In this way, the neurovascular supply to the anterior portion of the gluteus maximus muscle is not at risk. In addition, anterosuperior visualization and access are extended (Fig. 47-60). Having a straight, rather than angled, skin incision may make the modified Gibson more cosmetically appealing, especially in obese female patients.44 The modified Gibson approach can be used in conjunction with a trochanteric flip osteotomy.44 
Figure 47-59
Modified Gibson approach.
 
A: Straight skin incision. B: Fascial incision showing underlying anatomic structures. C: Deep dissection with the gluteus maximus muscle reflected and a retractor in the lesser sciatic notch (asterisk) showing posterior exposure similar to the Kocher–Langenbeck. Anterior retraction of the gluteus medius muscle without the presence of any overlying gluteus maximus muscle facilitates anterosuperior access.
 
(Copyright Berton R. Moed, MD.)
A: Straight skin incision. B: Fascial incision showing underlying anatomic structures. C: Deep dissection with the gluteus maximus muscle reflected and a retractor in the lesser sciatic notch (asterisk) showing posterior exposure similar to the Kocher–Langenbeck. Anterior retraction of the gluteus medius muscle without the presence of any overlying gluteus maximus muscle facilitates anterosuperior access.
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Figure 47-59
Modified Gibson approach.
A: Straight skin incision. B: Fascial incision showing underlying anatomic structures. C: Deep dissection with the gluteus maximus muscle reflected and a retractor in the lesser sciatic notch (asterisk) showing posterior exposure similar to the Kocher–Langenbeck. Anterior retraction of the gluteus medius muscle without the presence of any overlying gluteus maximus muscle facilitates anterosuperior access.
(Copyright Berton R. Moed, MD.)
A: Straight skin incision. B: Fascial incision showing underlying anatomic structures. C: Deep dissection with the gluteus maximus muscle reflected and a retractor in the lesser sciatic notch (asterisk) showing posterior exposure similar to the Kocher–Langenbeck. Anterior retraction of the gluteus medius muscle without the presence of any overlying gluteus maximus muscle facilitates anterosuperior access.
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Figure 47-60
Access provided by the modified Gibson approach.
 
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the quadratus femoris muscle origin. Solid black area shows the area of extended visualization and access.
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the quadratus femoris muscle origin. Solid black area shows the area of extended visualization and access.
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Figure 47-60
Access provided by the modified Gibson approach.
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the quadratus femoris muscle origin. Solid black area shows the area of extended visualization and access.
Dots delineate the available area of direct visualization. Horizontal lines delineate the area of indirect access. Vertical lines delineate the area of visualization and access extended by release of the quadratus femoris muscle origin. Solid black area shows the area of extended visualization and access.
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Modified Stoppa Intrapelvic Approach
The modified Stoppa intrapelvic approach is gaining wide acceptance as a substitute for the ilioinguinal approach (Fig. 47-61).157 As such, it was described for treating anterior wall, anterior column, transverse, T-shaped, anterior column/wall and posterior hemitransverse, and both-column fractures, initially only infrequently combined with the lateral window of the ilioinguinal approach.27 More recently, as its utility has been more fully appreciated, it is commonly used in conjunction with the lateral window.4,157 This approach is felt to be advantageous because it offers improved exposure of the quadrilateral surface and posterior column while minimizing dissection by avoiding the use of the “middle window” of the ilioinguinal approach.7,90 It is especially useful for fractures requiring buttress plating of the quadrilateral surface.151 
Figure 47-61
Modified Stoppa intrapelvic approach.
 
A: A transverse incision is made 2 cm above the symphysis. The linea alba is incised at the midline and split vertically from inferior to superior with care taken to remain extraperitoneal in the proximal portion. B: Protecting the bladder, the rectus abdominis muscle is then retracted upward. Sharp dissection is used to elevate the rectus to expose the symphysis body and pubic ramus. C: The rectus and neurovascular structures are subsequently retracted laterally and anteriorly so that they are protected. Any anastomotic vessels between major arteries, such as the inferior epigastric and obturator vessels, are ligated, as required. D: Full access is then developed from anterior to posterior along the pelvic brim, sharply dividing and elevating the iliopectineal fascia superiorly and the obturator fascia inferiorly and exposing the medial wall of the acetabulum, the fracture, and the pelvic brim. It is imperative to pay strict attention at all times to the location of the obturator neurovascular bundle and lumbosacral trunk which traverse the operative field. E: Cadaver dissection showing a scissors opening the obturator fascia. The obturator nerve (black arrow) is seen traversing the operative field just below the pelvic brim (white arrow).
 
(A–D: Modified from Cole JD, Bolhofner BR. Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop Relat Res. 1994;305:1154. E: Copyright Berton R. Moed, MD.)
A: A transverse incision is made 2 cm above the symphysis. The linea alba is incised at the midline and split vertically from inferior to superior with care taken to remain extraperitoneal in the proximal portion. B: Protecting the bladder, the rectus abdominis muscle is then retracted upward. Sharp dissection is used to elevate the rectus to expose the symphysis body and pubic ramus. C: The rectus and neurovascular structures are subsequently retracted laterally and anteriorly so that they are protected. Any anastomotic vessels between major arteries, such as the inferior epigastric and obturator vessels, are ligated, as required. D: Full access is then developed from anterior to posterior along the pelvic brim, sharply dividing and elevating the iliopectineal fascia superiorly and the obturator fascia inferiorly and exposing the medial wall of the acetabulum, the fracture, and the pelvic brim. It is imperative to pay strict attention at all times to the location of the obturator neurovascular bundle and lumbosacral trunk which traverse the operative field. E: Cadaver dissection showing a scissors opening the obturator fascia. The obturator nerve (black arrow) is seen traversing the operative field just below the pelvic brim (white arrow).
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Figure 47-61
Modified Stoppa intrapelvic approach.
A: A transverse incision is made 2 cm above the symphysis. The linea alba is incised at the midline and split vertically from inferior to superior with care taken to remain extraperitoneal in the proximal portion. B: Protecting the bladder, the rectus abdominis muscle is then retracted upward. Sharp dissection is used to elevate the rectus to expose the symphysis body and pubic ramus. C: The rectus and neurovascular structures are subsequently retracted laterally and anteriorly so that they are protected. Any anastomotic vessels between major arteries, such as the inferior epigastric and obturator vessels, are ligated, as required. D: Full access is then developed from anterior to posterior along the pelvic brim, sharply dividing and elevating the iliopectineal fascia superiorly and the obturator fascia inferiorly and exposing the medial wall of the acetabulum, the fracture, and the pelvic brim. It is imperative to pay strict attention at all times to the location of the obturator neurovascular bundle and lumbosacral trunk which traverse the operative field. E: Cadaver dissection showing a scissors opening the obturator fascia. The obturator nerve (black arrow) is seen traversing the operative field just below the pelvic brim (white arrow).
(A–D: Modified from Cole JD, Bolhofner BR. Acetabular fracture fixation via a modified Stoppa limited intrapelvic approach. Description of operative technique and preliminary treatment results. Clin Orthop Relat Res. 1994;305:1154. E: Copyright Berton R. Moed, MD.)
A: A transverse incision is made 2 cm above the symphysis. The linea alba is incised at the midline and split vertically from inferior to superior with care taken to remain extraperitoneal in the proximal portion. B: Protecting the bladder, the rectus abdominis muscle is then retracted upward. Sharp dissection is used to elevate the rectus to expose the symphysis body and pubic ramus. C: The rectus and neurovascular structures are subsequently retracted laterally and anteriorly so that they are protected. Any anastomotic vessels between major arteries, such as the inferior epigastric and obturator vessels, are ligated, as required. D: Full access is then developed from anterior to posterior along the pelvic brim, sharply dividing and elevating the iliopectineal fascia superiorly and the obturator fascia inferiorly and exposing the medial wall of the acetabulum, the fracture, and the pelvic brim. It is imperative to pay strict attention at all times to the location of the obturator neurovascular bundle and lumbosacral trunk which traverse the operative field. E: Cadaver dissection showing a scissors opening the obturator fascia. The obturator nerve (black arrow) is seen traversing the operative field just below the pelvic brim (white arrow).
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For this approach, the patient is placed in the supine position. Typically, the surgeon stands on the side opposite from the fracture to improve visualization of and access to the true intrapelvic cavity. A head lamp or a fiber optic light retractor may be useful as well.7 A transverse skin incision is made 2 cm above the pubic symphysis extending approximately from one external inguinal ring to the other. Deep dissection is performed through the linea alba (Fig. 47-61). With this approach, it is often necessary to make a second approach through a skin incision along the iliac crest for fracture reduction or hardware insertion, essentially using the equivalent of the lateral and medial “windows” of the ilioinguinal approach. Similar to the ilioinguinal approach, this approach requires indirect reduction of posterior fracture lines. The advantage over the ilioinguinal is that dissection of the iliac vessels is not required. However, this lack of access to the ilioinguinal middle “window” is also its potential disadvantage. The limiting factor in the exposure is the extent of vertical dissection of the rectus, not lateral dissection superficial to the rectus.7 With this approach, it is particularly important to locate the obturator nerve. As with the ilioinguinal approach, a safe zone has been identified to assist in avoiding intra-articular screw placement.59 
Combined Anterior and Posterior Approaches
The anterior ilioinguinal or iliofemoral approach and the posterior Kocher–Langenbeck approach can be combined and performed sequentially or simultaneously.66,93,155 The sequential tactic is employed when a standard anterior or posterior single approach proves ineffective for reduction and/or fixation of the opposite column. This can occur for anterior and posterior hemitransverse, T-shaped, or associated both-column fractures. In this situation, the operating surgeon is careful not to place fixation into the opposite column during the original procedure. The patient is then repositioned for a second standard approach, either during the same anesthesia or at a later date. The simultaneous anterior and posterior approach tactic is distinctly different. In either situation, care should be taken to maximize the skin bridge between the two approaches and avoid undermining the subcutaneous tissues between the exposures. 
For two simultaneous approaches, the patient is positioned laterally. Two simultaneous approaches theoretically allow access to both the anterior and posterior columns without the morbidity of the extended approach. The combined access, however, does not include the exposure of the external surface of the posterior superior ilium that the extended iliofemoral approach allows. In addition, the lateral patient positioning frequently compromises both exposures. Frequently, only the lateral window of the ilioinguinal can be used. Simultaneous iliofemoral and Kocher–Langenbeck surgical approaches performed by two surgical teams operating concurrently have been used successfully for both-column fractures with associated posterior wall fractures, comminuted transverse transtectal fractures, transverse and posterior wall fractures with wide displacement, and T-shaped fractures.66 

Operative Treatment of Elementary Acetabular Fracture Types

Open Reduction and Internal Fixation of Posterior Wall Fractures

Preoperative Planning.
Open reduction and internal fixation of a posterior wall fracture requires standard 3.5-mm hardware, including malleable reconstruction-type plates, one-third tubular plates, and 3.5-mm cortical screws (Table 47-8). Cortical fully threaded miniscrews (1.5-mm and 2-mm) and 1.5-mm bioabsorbable pegs are helpful in securing small osteochondral fragments often associated with these fractures. In addition, small wall fragments often require 2.7-mm screws for fixation. Many manufacturers make these implants. However, miniscrews with a smaller, flatter cruciate head are much easier to countersink below the cancellous bone surface. We have found the most common miniscrew and bioabsorbable peg length to be 40 mm; therefore, screws of 40 to 50 mm in length (which usually are not part of standard miniscrew fracture fixation sets) should be on hand. A pointed ball spike (Fig. 47-45B) is useful for holding small fragments in position during the reduction and fixation sequence. A modified one-third tubular plate (spring plate) can be helpful in stabilizing small posterior wall fragments (Fig. 47-62). Posterior wall fractures are often comminuted with intra-articular free and marginally impacted fragments (Figs. 47-13 and 47-17).93,120,121,126 It is important preoperatively to define the extent and location of these fragments to be prepared for and facilitate their intraoperative identification, reduction, and fixation (Tables 47-8 and 47-9). 
(Copyright Berton R. Moed, MD.)
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Figure 47-62
Photographs of a one-third tubular plate fashioned into a spring plate.
(Copyright Berton R. Moed, MD.)
(Copyright Berton R. Moed, MD.)
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Table 47-8
ORIF of Posterior Wall Fractures Preoperative Planning Checklist
  •  
    OR table: Purpose-built fracture table or standard radiolucent table
  •  
    Position: Prone or lateral
  •  
    Flouroscopy location: Opposite to the side of the operating surgeon
  •  
    Equipment: Purpose-specific reduction clamps
    •  
      Method for joint distraction (fracture table, distractor, or Schanz screw)
    •  
      K-wires for temporary fixation
    •  
      Oscillating drill
    •  
      Sciatic nerve retractor
  •  
    Implants: Purpose-specific 3.5-mm reconstruction plates
    •  
      One-third tubular plates
    •  
      Wide array of 1.5-, 2-, 2.7-, and 3.5-mm screws; 1.5-mm bioabsorbable pegs
  •  
    Bone graft material: Source of autograft, allograft, or bone substitute to serve as a void filler
X
 
Table 47-9
ORIF of Posterior Wall Fractures Surgical Steps
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Table 47-9
ORIF of Posterior Wall Fractures Surgical Steps
  •  
    Expose posterior wall and column
  •  
    Protect sciatic nerve
  •  
    Carefully delineate posterior wall fragments while maintaining capsular attachments
  •  
    Apply traction to distract the joint using:
    •  
      OR table
    •  
      Universal distractor
    •  
      Manually through a trochanteric Schanz screw
  •  
    Remove free osteochondral fracture fragments
  •  
    Debride ligamentum teres
  •  
    Identify area(s) of marginal impaction
  •  
    Reduce femoral head to remaining intact acetabulum
  •  
    Using the femoral head as a template:
    •  
      Elevate and reduce marginal impaction
    •  
      Replace and reduce free osteochondral free fragments
    •  
      Temporarily fix fragments with 1.6-mm K-wires, as needed
    •  
      Fill underlying bone void with graft material
    •  
      Replace K-wires with bioabsorbable pegs or miniscrews, as needed
  •  
    Sequentially reduce posterior wall fragments using a ball-spiked pusher
  •  
    Individually fix the wall fragments using lag screws without excessive tightening
  •  
    Buttress the construct using a well-contoured 3.5-mm reconstruction plate
  •  
    Insert additional lag screws, as needed
  •  
    Fully tighten all lag screws
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Positioning.
The patient can be positioned either prone on a specialized fracture table (Fig. 47-42) or laterally on a radiolucent operating table with a beanbag used for support as previously described. In either case, the C-arm for intraoperative fluoroscopic imaging is placed on the side opposite to the operating surgeon. The knee should remain flexed throughout the procedure to reduce tension and risk of injury to the sciatic nerve.16,93 Although most surgeons are more comfortable with lateral positioning, with prone positioning of the patient, hip and knee position are controlled, thereby minimizing the risk of iatrogenic nerve injury.16 The position of the femoral head is controlled and facilitates the repositioning of free osteochondral or impacted fragments using the head as a template. 
Surgical Approach.
The Kocher–Langenbeck approach is ideal for posterior wall fractures. However, for special circumstances, such as the need for increased exposure to address posterior superior fracture lines or large wall fragments incarcerated in the joint, a modified Gibson approach or possibly a trochanteric flip osteotomy may be needed. Both of these situations should be anticipated from the preoperative planning. A lateral patient position may be required. 
Technique.
After the surgical approach is completed, exposing the posterior wall and column, the posterior wall fracture fragments then must be carefully delineated and cleared of debris (Table 47-9). The surgeon must be cognizant of the capsular blood supply to the articular fragments. Limiting periosteal elevation to the fracture site helps to avoid further devascularization and under no circumstances should any fragment be released from its capsular attachment. Rotating the fragments on their capsulolabral attachments still allows visualization of the fragments, the articular surface, and the joint itself. The femoral head is distracted and free osteochondral fragments are removed from the joint. As previously described, distraction of the femoral head can be accomplished using traction applied from the fracture table (Fig. 47-42), from a universal distractor (Fig. 47-43), or manually through a T-handle chuck on a Schanz screw temporarily placed through the greater trochanter into the femoral neck. Retrieval of large osteochondral fragments may require that the hip actually be subluxated temporarily. The position and orientation of the free osteochondral fragments should be noted as this information may help the surgeon in figuring out where to replace each fragment. The ligamentum teres is debrided from the cotyloid fossa and the joint is thoroughly irrigated to ensure that all debris has been removed. The rationale behind debriding the ligamentum is that the tissue, once torn by the dislocation, may be interposed between the femoral head and the intact acetabulum. If this causes the femoral head to sit incongruently in the joint during reduction of the posterior wall fragments, the joint may be reconstructed incorrectly. If a fragment of the posterior wall is incarcerated within the joint, the capsular attachments should not be sacrificed to retrieve the fragment. The capsular hinge is usually at the anterior aspect of the wall fragment, which (as noted above) may be difficult to access though a Kocher–Langenbeck approach. 
Next, the femoral head is reduced to the intact acetabular cartilage. This allows the femoral head to be used as a template for the reduction of free articular fragments and marginal impaction. Impacted fragments should be mobilized with underlying cancellous bone, reduced against the head, and held provisionally in place. Then, any free osteochondral fragments are likewise reduced against the head, and held provisionally in place. Any remaining underlying bony defect is filled with structural graft. Bone graft is most often easily obtained from a window in the greater trochanter and synthetic bone void fillers have been used for this purpose. However, freeze-dried cancellous allograft bone is preferred (Fig. 47-63). Once these fragments are reduced, it is difficult to hold them in their positions while reducing the overlying main wall fragment(s). It is useful to provisionally fix the articular fragments with 1.6-mm K-wires and to exchange these for subchondral mini screws or bioabsorbable pegs (Figs. 47-64 and 47-65). Final reduction of the fragments is performed using a ball-spiked pusher and direct visualization of the reduction on the retroacetabular surface (Fig. 47-66). The overlying posterior wall fragments are then fixed with lag screws, with at least one screw in each articular fragment. Smaller fragments may require 2.4- or 2.7-mm lag screws. Very small rim fragments may require the use of a spring plate. Because the direction of the lag screws can rarely be perpendicular to the fracture, excessive tightening of the screws can displace the wall fragments. The lag screws must be supplemented with a buttress plate that spans the posterior wall fragments from the ischium to the intact ilium.121 Following plate application, the lag screws in the wall can be fully tightened. This method of fixation has been termed “two-level reconstruction.”52 Lag screws placed close to the posterior rim can be confirmed to be extra-articular by using C-arm visualization directly down the long axis of the screw or tangential to the screw to confirm that the screw is placed in an extra-articular location, but should be performed prior to buttress plate fixation obscuring the view.29 The buttress plate should be slightly undercontoured so as to provide compression to the posterior wall when tightened. Excessive undercontouring can cause the fragment to be over-reduced, which may prevent the femoral head from fully seating into the acetabulum. The buttress plate is best placed parallel and close to the rim of the acetabulum, where it can provide the best buttress for the wall fragments (Fig. 47-67). Ideally, three screws are placed cephalad to the fracture fragments and two placed distal, with one of them being a long screw into the ischium (Fig. 47-44A and 47-67). 
Figure 47-63
 
Intraoperative photograph demonstrating elevation of the marginal impaction (white arrowhead) with the femoral head (asterisk) used as a template and the filling of the residual osseous cavity with allograft cancellous bone from the patient shown in Figure 45-17. (From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107. Permission granted.)
Intraoperative photograph demonstrating elevation of the marginal impaction (white arrowhead) with the femoral head (asterisk) used as a template and the filling of the residual osseous cavity with allograft cancellous bone from the patient shown in Figure 45-17. (From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107. Permission granted.)
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Figure 47-63
Intraoperative photograph demonstrating elevation of the marginal impaction (white arrowhead) with the femoral head (asterisk) used as a template and the filling of the residual osseous cavity with allograft cancellous bone from the patient shown in Figure 45-17. (From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107. Permission granted.)
Intraoperative photograph demonstrating elevation of the marginal impaction (white arrowhead) with the femoral head (asterisk) used as a template and the filling of the residual osseous cavity with allograft cancellous bone from the patient shown in Figure 45-17. (From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107. Permission granted.)
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Figure 47-64
 
Intraoperative photograph showing an example of temporary Kirschner wire fixation after elevation of the impacted intra-articular fragments. The residual underlying cancellous bone defect has been filled with freeze-dried cancellous allograft bone. The Kirschner wires were subsequently exchanged for bioabsorbable pegs.
 
(Copyright Berton R. Moed, MD.)
Intraoperative photograph showing an example of temporary Kirschner wire fixation after elevation of the impacted intra-articular fragments. The residual underlying cancellous bone defect has been filled with freeze-dried cancellous allograft bone. The Kirschner wires were subsequently exchanged for bioabsorbable pegs.
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Figure 47-64
Intraoperative photograph showing an example of temporary Kirschner wire fixation after elevation of the impacted intra-articular fragments. The residual underlying cancellous bone defect has been filled with freeze-dried cancellous allograft bone. The Kirschner wires were subsequently exchanged for bioabsorbable pegs.
(Copyright Berton R. Moed, MD.)
Intraoperative photograph showing an example of temporary Kirschner wire fixation after elevation of the impacted intra-articular fragments. The residual underlying cancellous bone defect has been filled with freeze-dried cancellous allograft bone. The Kirschner wires were subsequently exchanged for bioabsorbable pegs.
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Figure 47-65
 
Drawing of the hip after fracture fragment repositioning, bone grafting, and stabilization with use of a subchondral miniscrew. (Redrawn after Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]: 87–107.) Permission granted.
Drawing of the hip after fracture fragment repositioning, bone grafting, and stabilization with use of a subchondral miniscrew. (Redrawn after Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]: 87–107.) Permission granted.
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Figure 47-65
Drawing of the hip after fracture fragment repositioning, bone grafting, and stabilization with use of a subchondral miniscrew. (Redrawn after Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]: 87–107.) Permission granted.
Drawing of the hip after fracture fragment repositioning, bone grafting, and stabilization with use of a subchondral miniscrew. (Redrawn after Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]: 87–107.) Permission granted.
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Figure 47-66
The posterior wall fragments are sequentially reduced and held with the ball spike.
 
Screws are inserted whereas the reduction is maintained by the ball spike, obviating the need for temporary Kirschner wire fixation. The accuracy of the reduction of the articular surface is extrapolated from the reduction along the acetabular rim and that of the extra-articular cortical fracture lines.
 
(From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107.) Permission granted.
Screws are inserted whereas the reduction is maintained by the ball spike, obviating the need for temporary Kirschner wire fixation. The accuracy of the reduction of the articular surface is extrapolated from the reduction along the acetabular rim and that of the extra-articular cortical fracture lines.
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Figure 47-66
The posterior wall fragments are sequentially reduced and held with the ball spike.
Screws are inserted whereas the reduction is maintained by the ball spike, obviating the need for temporary Kirschner wire fixation. The accuracy of the reduction of the articular surface is extrapolated from the reduction along the acetabular rim and that of the extra-articular cortical fracture lines.
(From Moed BR, McMichael JC. Outcomes of posterior wall fractures of the acetabulum. Surgical technique. J Bone Joint Surg Am. 2008;90A[suppl 1]:87–107.) Permission granted.
Screws are inserted whereas the reduction is maintained by the ball spike, obviating the need for temporary Kirschner wire fixation. The accuracy of the reduction of the articular surface is extrapolated from the reduction along the acetabular rim and that of the extra-articular cortical fracture lines.
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Figure 47-67
 
Intraoperative C-arm fluoroscopy showing extra-articular placement of two 2.7-mm lag screws and the buttress plate appropriately positioned for a small posterior wall fragment. (Copyright Berton R. Moed, MD.)
Intraoperative C-arm fluoroscopy showing extra-articular placement of two 2.7-mm lag screws and the buttress plate appropriately positioned for a small posterior wall fragment. (Copyright Berton R. Moed, MD.)
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Figure 47-67
Intraoperative C-arm fluoroscopy showing extra-articular placement of two 2.7-mm lag screws and the buttress plate appropriately positioned for a small posterior wall fragment. (Copyright Berton R. Moed, MD.)
Intraoperative C-arm fluoroscopy showing extra-articular placement of two 2.7-mm lag screws and the buttress plate appropriately positioned for a small posterior wall fragment. (Copyright Berton R. Moed, MD.)
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Potential Pitfalls and Preventative Measures.
During the surgical approach, the gluteus maximus muscle is split, which should stop as soon as the first nerve branch to the upper part of the muscle is encountered (Table 47-10) (Fig. 47-48). There is no internervous plane, and the nerve branches of the upper one-third of the muscle cross the intended interval of dissection slightly more than halfway between the level of the greater trochanter and the posterior superior iliac spine. Therefore, if these branches are cut, the anterior one-third of the muscle will be denervated. The sciatic nerve is at risk during the entire surgery. Great care should be observed during exposure and retraction of the sciatic nerve. The surgical assistant in charge of maintaining position of the retractor must be cognizant of the importance of this task. The position of the retractor should be checked frequently during the operative procedure. Knee flexion should be maintained throughout the procedure to limit stretch on the nerve. Iatrogenic femoral head osteonecrosis can be caused by overly aggressive dissection near the posterior aspect of the proximal femur near the insertion of the short external rotators. This is where the deep medial circumflex femoral artery runs its course to supply the femoral head (Fig. 47-35A). It is for this reason that the tendons of the short external rotators and the piriformis muscles are released at least 1.5 cm from their insertions. Iatrogenic osteonecrosis of the posterior wall fracture fragments is caused by excessive stripping of their soft tissue attachments. Every attempt should be made to maintain the capsular attachments to these posterior wall fragments. Final tightening of lag screws that are not perpendicular to the fracture line should not be performed until the buttress plate has been applied. Otherwise the fragments may shift. Lag screws should always be placed along the rim of posterior wall fragments, and care should be taken to ensure that plate buttressing the posterior wall is positioned as lateral as possible. Positioning the buttress plate too medially (away from the rim), especially without rim lag screw fixation, may result in loss of stabilization of the posterior wall. Finally, care should be taken to ensure that the buttress plate either exactly fits the contour of the posterior wall and column or is slightly undercontoured. An overcontoured plate will leave a gap between the posterior wall and the plate, not buttressing the fracture and risking loss of reduction. An undercontoured plate may crush the posterior wall or cause the fracture fragments to shift as the screws in the plate are tightened. Finally, extra-articular position of all screws should be confirmed using C-arm fluoroscopy before leaving the operating room.29 
Table 47-10
ORIF of Posterior Wall Fractures Potential Pitfalls and Preventions
Pitfall Preventions
1. Injury to the first nerve branch to the upper part of the gluteus maximus muscle Stop dissection as soon as the nerve is encountered
Maintain knee flexion
2. Sciatic nerve injury Maintain knee flexion
Identify the nerve superficial to the quadratus femoris muscle
Use a purpose-specific nerve retractor
Check retractor position often
3. Iatrogenic femoral head osteonecrosis Avoid aggressive dissection near the insertion of the short external rotators
Release the short external rotator and piriformis tendons at least 1.5 cm from their insertions
4. Iatrogenic osteonecrosis of the posterior wall fracture fragments Avoid excessive stripping of the soft tissue attachments
Identify the nerve superficial to the quadratus femoris muscle
Use a purpose-specific nerve retractor
Check retractor position often
5. Malposition or loss of reduction of intra-articular fragments Careful initial reduction
Bone graft residual bone voids
Individually fix the fragments, if possible
6. Loss of posterior wall reduction Fix each fragment with lag screws
Accurately contour the buttress plate
Place additional lag screws along the rim
7. Intra-articular screw placement Confirm extra-articular screw position using C-arm fluoroscopy before leaving the operating room
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Open Reduction and Internal Fixation of Posterior Column Fractures

Preoperative Planning.
Open reduction and internal fixation of a posterior column fracture requires standard 3.5-mm hardware, including malleable reconstruction-type plates and 3.5-mm cortical screws (Table 47-11). Cortical 4.5-mm cortical screws may also be required, either to serve as anchor points for reduction clamps or as a lag screw across the column fracture. Angle-jawed offset and Jungbluth clamps are often required for the reduction maneuvers. 
Table 47-11
ORIF of Posterior Column Fractures Preoperative Planning Checklist
  •  
    OR table: Purpose-built fracture table or standard radiolucent table
  •  
    Position: Prone or lateral
  •  
    Fluoroscopy location: Opposite to the side of the operating surgeon
  •  
    Equipment: Purpose-specific reduction clamps
    •  
      Method for joint distraction:
    •  
      Fracture table, distractor, or Schanz pin
    •  
      Method for column derotation:
    •  
      Schanz pin or specialized reduction clamps
    •  
      Oscillating drill
    •  
      Sciatic nerve retractor
  •  
    Implants: Purpose-specific 3.5-mm reconstruction plates
    •  
      Array of 3.5- and 4.5-mm screws
X
Positioning and Surgical Approach.
Patient positioning is similar as that for the posterior wall. In addition to the possible advantages of prone positioning mentioned in that section, with lateral positioning, the weight of the operative leg tends to cause medial displacement of the femoral head with further medial displacement and malrotation of the fractured posterior column fragments. Furthermore, access through the greater sciatic notch for palpation and clamp placement is facilitated by use of prone positioning. Inserting the lag screw at the desired position and angle is often a difficult task. The prone position is helpful in this regard. 
The preferred surgical approach is the Kocher–Langenbeck. One important additional consideration is that the posterior column fracture frequently involves the greater sciatic notch at or above the location of the superior gluteal neurovascular bundle. In widely displaced fractures, it is common to find the neurovascular bundle in the posterior column fracture site and it must be carefully extracted before reduction of the fracture to prevent iatrogenic injury. 
Technique.
Whenever the posterior column is involved, as it is in most fracture types (posterior column, posterior column and wall, transverse, transverse and posterior wall, T-shaped, anterior and posterior hemitransverse, and both-column), there is a rotational as well as translational displacement of this component (Table 47-12). The rotational mismatch of the posterior column can be best assessed by palpation through the greater sciatic notch. Insertion of a Schanz screw into the ischium to be used as a joystick for manipulation of the posterior column fragment is an important step in correcting this multiplanar displacement (Fig. 47-68A). For fractures that involve only the posterior column (posterior column with or without a posterior wall component), one additional reduction clamp is usually required to complete the reduction. This reduction clamp is placed on the retroacetabular surface on either side of the fracture line. If there is no comminution in the column, a standard pointed reduction clamp can be used (Fig. 47-68B). An angle-jawed offset clamp can also be used for this purpose (Figs. 47-45A and 47-69). If comminution is present, requiring the length of the column to be restored, a clamp that has distraction capabilities, such as a Jungbluth, should be used (Fig. 47-45B), which is fixed to each fracture fragment using a 4.5-mm screw (Fig. 47-70). It may be helpful to use a ball-spiked pusher to push the posterior column from posterior to anterior. The reduction is visualized on the intact retroacetabular surface and is palpated on the quadrilateral surface through the greater sciatic notch. The posterior column fracture is then secured to the intact ilium with interfragmentary screw fixation inserted from posterior to anterior and directed toward the pelvic brim (keeping in mind the frontal plane nature of the fracture). Secure lag screw fixation is critical to maintain the reduction and is easily performed perpendicular to the fracture plane in all except the lowest and high posterior column fractures. In these more difficult situations, insertion of the lag screw using a percutaneous, transgluteal technique should be considered.34 The lag screws are supplemented with a neutralization plate on the retroacetabular surface (Fig. 47-44B). However, in distinction to the posterior wall, here the plate contour should exactly match the bone. If the lag screw fixation is not secure, an undercontoured plate can “pull” the posterior column fracture to the plate, resulting in a loss of the articular reduction. If there is extensive comminution precluding lag screw fixation, dual plating should be considered, using a short plate bridging the fracture placed along the greater sciatic notch. 
Figure 47-68
 
A: Drawing of a hemipelvis showing a Schanz screw in the ischium, which is used to control rotational, as well as translational, displacement of the posterior column seen in a number of fracture types. (Copyright Berton R. Moed, MD.) B: Plastic bone model showing a fracture of the posterior column with a pointed reduction clamp applied.
 
(Modified from Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9A, page 688.)
A: Drawing of a hemipelvis showing a Schanz screw in the ischium, which is used to control rotational, as well as translational, displacement of the posterior column seen in a number of fracture types. (Copyright Berton R. Moed, MD.) B: Plastic bone model showing a fracture of the posterior column with a pointed reduction clamp applied.
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Figure 47-68
A: Drawing of a hemipelvis showing a Schanz screw in the ischium, which is used to control rotational, as well as translational, displacement of the posterior column seen in a number of fracture types. (Copyright Berton R. Moed, MD.) B: Plastic bone model showing a fracture of the posterior column with a pointed reduction clamp applied.
(Modified from Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9A, page 688.)
A: Drawing of a hemipelvis showing a Schanz screw in the ischium, which is used to control rotational, as well as translational, displacement of the posterior column seen in a number of fracture types. (Copyright Berton R. Moed, MD.) B: Plastic bone model showing a fracture of the posterior column with a pointed reduction clamp applied.
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Figure 47-69
Offset clamp shown across a posterior column fracture in a plastic bone model.
 
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9 B, page 688).
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9 B, page 688).
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Figure 47-69
Offset clamp shown across a posterior column fracture in a plastic bone model.
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9 B, page 688).
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9 B, page 688).
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Figure 47-70
A Jungbluth reduction clamp anchored with screws on either side of a posterior column fracture shown in a plastic bone model.
 
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9 C, page 689).
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9 C, page 689).
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Figure 47-70
A Jungbluth reduction clamp anchored with screws on either side of a posterior column fracture shown in a plastic bone model.
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9 C, page 689).
(From Tile M, Helfet DL, Kellam JF. Fractures of the Pelvis and Acetabulum. Philadelphia, PA: Lippincott Williams & Wilkins; 2003, Fig. 36-9 C, page 689).
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Table 47-12
ORIF of Posterior Column Fractures Surgical Steps
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Table 47-12
ORIF of Posterior Column Fractures Surgical Steps
  •  
    Expose posterior wall and column
  •  
    Protect sciatic nerve
  •  
    Carefully delineate fracture fragments and the fracture line
  •  
    Apply traction to distract the joint using:
    •  
      OR table
    •  
      Universal distractor
    •  
      Manually through a trochanteric Schanz screw
  •  
    Remove any intra-articular debris
  •  
    Reduce femoral head to the intact acetabulum maintaining traction to unload the column fracture fragment(s)
  •  
    Insert a Schanz screw into the ischium to use in correcting fracture malrotation
  •  
    Place the appropriate reduction clamp, as required, across the fracture
  •  
    Reduce the fracture by manipulating the Schanz screw and reduction clamp
  •  
    Insert a lag screw across the fracture
  •  
    If lag screw fixation is not possible, place a short 3.5-mm reconstruction plate across the fracture
  •  
    Neutralize the construct using a well-contoured 3.5-mm reconstruction plate
X
Potential Pitfalls and Preventative Measures.
All the concerns relative to the surgical approach for the posterior wall mentioned in Table 47-10 apply (Table 47-13). In addition, one must take great care in exposing the superior aspect of the fracture line at the greater sciatic notch to ensure that the superior gluteal neurovascular bundle is not injured. Furthermore, the posterior superior aspect of the posterior column fracture fragment may end in a long thin and sharp point. Removing this sharp tip with a rongeur can minimize the risk of injury to the superior gluteal neurovascular bundle and may facilitate the reduction. Residual malrotation of the column fracture is a common problem. Although it may appear well reduced on its external surface, correction of the malrotation can only be insured by additional assessment of the intrapelvic aspect of the fracture line. This can be accomplished by digital palpation through the greater sciatic notch. Shortening of the column in comminuted fractures is another potential pitfall. This can be avoided by using a reduction clamp capable of distracting the column out to length (e.g., Jungbluth clamp) and using a short bridge plate rather than a lag screw. To avoid having the neutralization plate cause loss of reduction, it must be perfectly contoured to match the bone. As with all acetabular fracture fixations, extra-articular position of all screws should be confirmed using C-arm fluoroscopy before leaving the operating room.29 
Table 47-13
ORIF of Posterior Column Fractures Potential Pitfalls and Preventions
Pitfall Preventions
1. Injury to the superior gluteal neurovascular bundle Exercise great care in exposing the fracture line at the greater sciatic notch
2. Residual malrotation of the posterior column fracture fragment Ensure the malrotation is corrected by digital palpation through the greater notch of the intrapelvic aspect of the fracture line
3. Shortening of the posterior column In a comminuted fracture ensure that the column has been brought out to length using the appropriate reduction clamp in distraction
Use a short bridging plate rater than a lag screw
4. Loss of posterior column reduction Accurately contour the neutralization plate
5. Intra-articular screw placement Confirm extra-articular screw position using C-arm fluoroscopy before leaving the operating room
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Open Reduction and Internal Fixation of Anterior Column Fractures and Anterior Wall Fractures

Preoperative Planning.
The ball-spiked pusher is often required to assist in holding or correcting malrotation of the fracture fragments (Table 47-14). In addition, various sizes of angel-jawed offset reduction forceps may be required to address displaced fractures of the quadrilateral surface (Fig. 47-45A). The Farabeuf and serrated reduction forceps (Fig. 47-45B) are very useful in grasping the displaced anterior column. The standard 3.5-mm implants, including malleable reconstruction-type plates and long 3.5-mm cortical screws, are adequate for fracture fixation. Occasionally, 4.5-mm cortical lag screws inserted at the level of the anterior inferior iliac spine are used for fixation of the anterior column. 
Table 47-14
ORIF of Anterior Wall and Column Fractures Preoperative Planning Checklist
  •  
    OR table: Purpose-built fracture table or standard radiolucent table
  •  
    Position: Supine
  •  
    Flouroscopy location: Opposite to the side of the operating surgeon
  •  
    Equipment: Purpose-specific reduction clamps
    •  
      Method for joint distraction:
    •  
      Fracture table, distractor, or Schanz screw
    •  
      K-wires for temporary fixation
    •  
      Oscillating drill
  •  
    Implants: Purpose-specific 3.5-mm reconstruction plates
    •  
      One-third tubular plates
    •  
      Wide array of 3.5- and 4.5-mm screws
X
Positioning.
The patient can be positioned supine either on a specialized fracture table or on a radiolucent operating table. In either case, the C-arm for intraoperative fluoroscopic imaging is placed on the side opposite to the operating surgeon. The knee is slightly flexed throughout the procedure to reduce tension and risk of injury to the sciatic nerve and the hip is slightly flexed to relax the iliopsoas tendon and femoral nerve and vessels. The ipsilateral arm can either be abducted to 90 degrees or draped across the chest to minimize the risk of a positional hyperabduction injury. 
Surgical Approach.
The ilioinguinal approach is indicated for fractures involving the anterior wall and column.93,107 It warrants repeating that this approach does not allow direct access to the hip joint and fractures requiring direct visualization for removal of intra-articular debris or fracture fixation may require a distal extension in the plane between the sartorius and tensor fascia lata muscle distal to the inguinal ligament, as in the iliofemoral approach.85 
As an alternative, the iliofemoral approach may be sufficient for high anterior column fractures in which the main displacement is cephalad to the hip joint (Table 47-7). If the quadrilateral surface is comminuted and requires fixation for reason(s) of joint stability and/or congruency, as previously described, the modified Stoppa approach may be a better surgical choice to accomplish direct plating and buttressing of the fracture. 
Technique.
Anterior column fractures may be commonly associated with anterior sacroiliac joint opening and external rotation of the “intact” portion of the ilium (Table 47-15). This should be reduced before attempting reduction of the anterior column and may be internally fixed with a single two-hole plate (one screw in the sacrum and one in the ilium). Additional stability for this rotational injury results from the fixation of the anterior column fracture. 
 
Table 47-15
ORIF of Anterior Column and Wall Fractures Surgical Steps
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Table 47-15
ORIF of Anterior Column and Wall Fractures Surgical Steps
  •  
    Determine appropriate surgical approach and whether quadrilateral surface comminution is present
  •  
    Expose anterior wall and column
  •  
    Carefully clear the fracture lines of debris
  •  
    Apply traction to unload the joint using:
    •  
      OR table
    •  
      Manually through a trochanteric Schanz screw
  •  
    Reduce femoral head to remaining intact acetabulum
  •  
    Correct fracture translation and malrotation using appropriate reduction instruments
  •  
    Fix fractured column or wall using lag screws
  •  
    Buttress any quadrilateral surface comminution, as required
    •  
      Use middle window of the ilioinguinal approach
    •  
      Use modified Stoppa extension of medial window of the ilioinguinal approach
    •  
      Select modified Stoppa approach for the surgery
  •  
    Buttress the construct using a well-contoured 3.5-mm reconstruction plate
X
The common deformity seen in large anterior column fractures is proximal, medial displacement with a component of external rotation. Occasionally, the anterior column fracture is found to be incomplete with the fracture line not exiting the iliac crest. The displacement of the column occurs through comminution or plastic deformation in the very thin central portion of the iliac wing. It is often not possible to achieve a complete reduction of the anterior column in this situation without completing the fracture by osteotomizing the iliac crest. This improves the mobility of the anterior column fragment for reduction. The reduction of the anterior column is assessed primarily through the lateral and middle windows and the fracture is reduced with a combination of pelvic clamps positioned at the iliac crest, interspinous notch, and pelvic brim. Since the articular surface of the hip joint is not seen directly, the reduction must be assessed by the appearance of the extra-articular fracture lines and intraoperative fluoroscopic assessment. Care must be taken to restore the normal concavity to the internal iliac fossa. Residual external rotation or flexion of the anterior column fracture is appreciated as a gap in the fracture site at the pelvic brim. When the rotation of the anterior column is correct, the anterior inferior iliac spine should be aligned with the nutrient foramen of the ilium. 
A Farabeuf clamp on the displaced segment, in addition to a ball-spiked pusher in the pelvic brim area, can facilitate derotation (Fig. 47-71). A large or small pointed reduction forceps can reduce and hold the fracture line at the iliac crest, and a large pelvic reduction forceps inserted deep into the region of the pelvic brim can hold the reduction during screw stabilization. For the trapezoidal-shaped fractures of the anterior wall, the reduction is usually accomplished by in-line traction in combination with a straight ball spike. Reduction is facilitated by hip flexion, in order to relax structures crossing anterior to the hip joint. Though difficult to apply, a large offset reduction forceps or oblique reduction forceps with pointed ball tips, usually inserted via in the middle window of the ilioinguinal approach, can be very helpful (Fig. 47-72). 
Figure 47-71
A Farabeuf reduction forceps is on the iliac crest, correcting medial displacement and external malrotation.
 
A straight ball spike placed through the middle window of the ilioinguinal approach and pushed in line with the arrow, is used to complete the reduction.
 
(From Tornetta P III, Riina J. Acetabular reduction techniques via the anterior approach. Op Tech Orthop. 1997;7:184–195. Permission granted.)
A straight ball spike placed through the middle window of the ilioinguinal approach and pushed in line with the arrow, is used to complete the reduction.
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Figure 47-71
A Farabeuf reduction forceps is on the iliac crest, correcting medial displacement and external malrotation.
A straight ball spike placed through the middle window of the ilioinguinal approach and pushed in line with the arrow, is used to complete the reduction.
(From Tornetta P III, Riina J. Acetabular reduction techniques via the anterior approach. Op Tech Orthop. 1997;7:184–195. Permission granted.)
A straight ball spike placed through the middle window of the ilioinguinal approach and pushed in line with the arrow, is used to complete the reduction.
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Figure 47-72
In some cases, it is advantageous to apply a large offset pelvic reduction forceps using the lateral or middle window of the ilioinguinal, as shown here.
 
If the middle window is used, the iliopsoas muscle and femoral nerve (represented respectively as a circle filled by oblique lines and a smaller black circle) lie between the arms of the clamp. The external iliac vessels (represented by an open circle) are medial.
 
(From Tornetta P III, Riina J. Acetabular reduction techniques via the anterior approach. Op Tech Orthop. 1997;7:184–195. Permission granted.)
If the middle window is used, the iliopsoas muscle and femoral nerve (represented respectively as a circle filled by oblique lines and a smaller black circle) lie between the arms of the clamp. The external iliac vessels (represented by an open circle) are medial.
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Figure 47-72
In some cases, it is advantageous to apply a large offset pelvic reduction forceps using the lateral or middle window of the ilioinguinal, as shown here.
If the middle window is used, the iliopsoas muscle and femoral nerve (represented respectively as a circle filled by oblique lines and a smaller black circle) lie between the arms of the clamp. The external iliac vessels (represented by an open circle) are medial.
(From Tornetta P III, Riina J. Acetabular reduction techniques via the anterior approach. Op Tech Orthop. 1997;7:184–195. Permission granted.)
If the middle window is used, the iliopsoas muscle and femoral nerve (represented respectively as a circle filled by oblique lines and a smaller black circle) lie between the arms of the clamp. The external iliac vessels (represented by an open circle) are medial.
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After obtaining the reduction, fixation of the anterior column can often be performed with lag screw fixation alone. Lag screws started just lateral to the pelvic brim and directed toward the sciatic notch or retroacetabular surface help to control the external rotation and flexion of the anterior column. A lag screw placed between the tables of the ilium at the iliac crest as well as one directed from the interspinous notch toward the posterior superior iliac spine completes the fixation. Inadequate screw purchase, osteoporotic bone, or screw fixation placed obliquely to the anterior column fracture line may require buttress plate supplementation (Figs. 47-44D and 47-73). When significant quadrilateral surface involvement is present that requires stabilization for reason(s) of joint stability and/or congruency, a plate bent in the shape of a “7” and placed from the pelvic brim extending caudad along the quadrilateral plate can buttress the fracture (Fig. 47-74). Specialized plates are also available for this purpose. Fixation is achieved either with screws through the plate, a second buttress plate applied along the pelvic brim with screws inserted lateral and medial to the hip joint, or a combination of both (Fig. 47-75). This plating technique is very difficult to effectively accomplish using the standard ilioinguinal approach. Therefore, direct plating and buttressing of the quadrilateral surface injury through an alternative approach, the modified Stoppa approach, may be a better surgical tactic (Fig. 47-76). However, the same exposure can be attained using the ilioinguinal approach by extending the incision medially across the midline and having the operating surgeon repositioned on the side of the OR table opposite to the fracture and work through the medial window.82,151 
Figure 47-73
Radiographic appearance at 6 months of the patient whose injury films are seen in Figure 47-22.
 
The anterior column has been fixed at the crest and interspinous notch with interfragmentary screws. A separate fragment of anterior wall comminution was buttressed with a plate that buttresses the anterior wall without actually spanning to the superior ramus (“push” plate). The comminuted superior ramus fracture has been left to heal unfixed.
The anterior column has been fixed at the crest and interspinous notch with interfragmentary screws. A separate fragment of anterior wall comminution was buttressed with a plate that buttresses the anterior wall without actually spanning to the superior ramus (“push” plate). The comminuted superior ramus fracture has been left to heal unfixed.
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Figure 47-73
Radiographic appearance at 6 months of the patient whose injury films are seen in Figure 47-22.
The anterior column has been fixed at the crest and interspinous notch with interfragmentary screws. A separate fragment of anterior wall comminution was buttressed with a plate that buttresses the anterior wall without actually spanning to the superior ramus (“push” plate). The comminuted superior ramus fracture has been left to heal unfixed.
The anterior column has been fixed at the crest and interspinous notch with interfragmentary screws. A separate fragment of anterior wall comminution was buttressed with a plate that buttresses the anterior wall without actually spanning to the superior ramus (“push” plate). The comminuted superior ramus fracture has been left to heal unfixed.
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Figure 47-74
A one-third tubular plate used to reduce and hold the comminuted quadrilateral surface in a plastic bone model.
 
This plate is usually supported by an overlying 3.5-mm reconstruction plate along the anterior column.
 
(From Tornetta P III, Riina J. Acetabular reduction techniques via the anterior approach. Op Tech Orthop. 1997;7:184–195. Permission granted.)
This plate is usually supported by an overlying 3.5-mm reconstruction plate along the anterior column.
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Figure 47-74
A one-third tubular plate used to reduce and hold the comminuted quadrilateral surface in a plastic bone model.
This plate is usually supported by an overlying 3.5-mm reconstruction plate along the anterior column.
(From Tornetta P III, Riina J. Acetabular reduction techniques via the anterior approach. Op Tech Orthop. 1997;7:184–195. Permission granted.)
This plate is usually supported by an overlying 3.5-mm reconstruction plate along the anterior column.
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Figure 47-75
Use of a quadrilateral buttress plate.
 
A: Initial AP radiograph of a 25-year-old female involved in a motor vehicle accident showing a fracture of the anterior column with a clinically important fracture fragment involving the quadrilateral surface (arrow). There is also a nondisplaced posterior hemitransverse component which is not evident on this film. B: Intraoperative fluoroscopic view showing the quadrilateral buttress plate held in position by an overlying plate with additional long screws inserted to stabilize the nondisplaced posterior hemitransverse component. The quadrilateral surface plate could not be held with screws alone without compromising the articular surface. C: Intraoperative photograph of the plate construct applied through the middle window of the ilioinguinal approach. D: AP pelvis radiograph showing a congruent joint and a normal joint space at 2-year follow-up when she was ambulating without assistive devices or pain, and her range of motion was symmetrical with a modified Merle d’Aubigné and Postel score of 18.
 
(Copyright Berton R. Moed, MD. Permission granted for nonexclusive unrestricted use.)
A: Initial AP radiograph of a 25-year-old female involved in a motor vehicle accident showing a fracture of the anterior column with a clinically important fracture fragment involving the quadrilateral surface (arrow). There is also a nondisplaced posterior hemitransverse component which is not evident on this film. B: Intraoperative fluoroscopic view showing the quadrilateral buttress plate held in position by an overlying plate with additional long screws inserted to stabilize the nondisplaced posterior hemitransverse component. The quadrilateral surface plate could not be held with screws alone without compromising the articular surface. C: Intraoperative photograph of the plate construct applied through the middle window of the ilioinguinal approach. D: AP pelvis radiograph showing a congruent joint and a normal joint space at 2-year follow-up when she was ambulating without assistive devices or pain, and her range of motion was symmetrical with a modified Merle d’Aubigné and Postel score of 18.
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Figure 47-75
Use of a quadrilateral buttress plate.
A: Initial AP radiograph of a 25-year-old female involved in a motor vehicle accident showing a fracture of the anterior column with a clinically important fracture fragment involving the quadrilateral surface (arrow). There is also a nondisplaced posterior hemitransverse component which is not evident on this film. B: Intraoperative fluoroscopic view showing the quadrilateral buttress plate held in position by an overlying plate with additional long screws inserted to stabilize the nondisplaced posterior hemitransverse component. The quadrilateral surface plate could not be held with screws alone without compromising the articular surface. C: Intraoperative photograph of the plate construct applied through the middle window of the ilioinguinal approach. D: AP pelvis radiograph showing a congruent joint and a normal joint space at 2-year follow-up when she was ambulating without assistive devices or pain, and her range of motion was symmetrical with a modified Merle d’Aubigné and Postel score of 18.
(Copyright Berton R. Moed, MD. Permission granted for nonexclusive unrestricted use.)
A: Initial AP radiograph of a 25-year-old female involved in a motor vehicle accident showing a fracture of the anterior column with a clinically important fracture fragment involving the quadrilateral surface (arrow). There is also a nondisplaced posterior hemitransverse component which is not evident on this film. B: Intraoperative fluoroscopic view showing the quadrilateral buttress plate held in position by an overlying plate with additional long screws inserted to stabilize the nondisplaced posterior hemitransverse component. The quadrilateral surface plate could not be held with screws alone without compromising the articular surface. C: Intraoperative photograph of the plate construct applied through the middle window of the ilioinguinal approach. D: AP pelvis radiograph showing a congruent joint and a normal joint space at 2-year follow-up when she was ambulating without assistive devices or pain, and her range of motion was symmetrical with a modified Merle d’Aubigné and Postel score of 18.
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Figure 47-76
Drawing showing the desired plate position for direct plating of an anterior column fracture with a multifragmented quadrilateral surface injury.
Rockwood-ch047-image076.png
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Fixation of anterior wall fractures is complicated by several factors. Secure clamp placement is difficult and can interfere with contoured plate placement. Interfragmentary screw fixation is often not possible without violating the hip joint. A screw placed very close to the pelvic brim and paralleling the quadrilateral surface may suffice to hold the wall fracture but will often be intra-articular within the cotyloid fossa. Once a lag screw is obtained (if possible), a buttress plate (which can be very slightly under bent to exert pressure on the fractured wall) is added with screws secured into the superior ramus below and the ilium above the wall fracture (Figs. 47-44C and 47-77). The morphology of the pelvic brim varies from patient to patient. The curve of the brim often follows a “J” pattern and the length is usually 13 holes in males and 12 holes in females for most fractures. The use of precontoured plates facilitates placement and reduces the number of times the plate is removed from the wound for contouring. 
Figure 47-77
Radiographic appearance at 8 months of the patient seen in Figure 47-19.
 
Two interfragmentary screws have been supplemented by a buttress plate that spans from the intact internal iliac fossa to the superior ramus. The central hole in the plate was used for a screw paralleling the quadrilateral surface.
Two interfragmentary screws have been supplemented by a buttress plate that spans from the intact internal iliac fossa to the superior ramus. The central hole in the plate was used for a screw paralleling the quadrilateral surface.
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Figure 47-77
Radiographic appearance at 8 months of the patient seen in Figure 47-19.
Two interfragmentary screws have been supplemented by a buttress plate that spans from the intact internal iliac fossa to the superior ramus. The central hole in the plate was used for a screw paralleling the quadrilateral surface.
Two interfragmentary screws have been supplemented by a buttress plate that spans from the intact internal iliac fossa to the superior ramus. The central hole in the plate was used for a screw paralleling the quadrilateral surface.
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Potential Pitfalls and Preventative Measures.
Injury to the lateral femoral cutaneous nerve can occur with either the iliofemoral or ilioinguinal approaches (Table 47-16). Because of the high risk of injury, patients should be advised of this likelihood preoperatively. The surgeon should identify the nerve’s location and avoid excessive stretch, if possible. Injury to the external iliac vessels can be avoided by avoiding excessive stretch and checking the vessels frequently, especially when reduction clamps have been placed in the middle window of the ilioinguinal approach. In adequate reduction of the anterior column malrotation is not uncommon. A gap in the fracture site at the pelvic brim or a lack of alignment of the anterior inferior iliac spine with the nutrient foramen of the ilium are indications that the reduction is inadequate. In situations requiring increased direct access to fractures of the quadrilateral surface (such as the need to plate the quadrilateral surface), the anterior intrapelvic (modified Stoppa) approach can be selected initially for the procedure or used in combination with the most lateral aspect (first window) of the ilioinguinal approach.32,157 For fractures involving the anterior wall and all those of the anterior column fractures except large fractures in good quality bone, a well contoured 3.5-mm reconstruction plate should be applied (buttress for the wall and neutralization for the column). 
Table 47-16
ORIF of Anterior Column and Wall Fractures Potential Pitfalls and Preventions
Pitfall Preventions
1. Injury to the lateral femoral cutaneous nerve Identify its location and avoid excessive stretch
2. Excessive bleeding during dissection of the middle window of the ilioinguinal approach Check for an anomalous origin of the obturator artery, or other anastomoses between the obturator and the external iliac systems
3. Injury (thrombosis) of the external iliac vessels Avoid excessive stretch, especially when reduction clamps are placed through the middle window of the ilioinguinal
Check frequently for a pulse in the artery
4. Injury to the sciatic nerve Avoid poor patient positioning and excessive traction
Be careful with drill bits and screws directed toward the greater sciatic notch
5. Residual malrotation of the anterior column fracture fragment Restore the normal concavity to the internal iliac fossa
Residual external rotation or flexion of the anterior column fracture is appreciated as a gap in the fracture site at the pelvic brim
Check to ensure that the anterior inferior iliac spine should be aligned with the nutrient foramen of the ilium
6. Loss of quadrilateral surface reduction Identify need for fixation preoperatively
Select proper surgical approach
Buttress using a second plate through the ilioinguinal approach or direct plating via the modified Stoppa approach
7. Loss of column or wall reduction Buttress lag screw fixation using an accurately contoured 3.5-mm reconstruction plate
8. Intra-articular screw placement Confirm extra-articular screw position using C-arm fluoroscopy before leaving the operating room
X

Open Reduction and Internal Fixation of Transverse Fractures

Preoperative Planning.
Open reduction and internal fixation of a transverse fracture requires standard 3.5-mm hardware, including malleable reconstruction-type plates and 3.5-mm cortical screws. Cortical 4.5-mm cortical screws may also be required, to serve as anchor points for reduction clamps or as a lag screw across the column fracture. In addition, extra-long screws (ranging in length from 65 mm to more than 100 mm depending on the screw angle, fracture line location, and patient size) of 3.5 mm, 4.5 mm, or possibly 6.5 mm in diameter are required for lag screw fixation of the anterior column fracture line. Other than having these lag screws, the preoperative planning checklist is no different than that for posterior column fractures (Table 47-11). 
Positioning and Surgical Approach.
Patient positioning is similar as that for the posterior column, again with the caveat that with lateral positioning, the weight of the operative leg tends to cause medial displacement of the femoral head with further medial displacement and malrotation of fractured inferior transverse fracture fragment. Derotation of the fracture around the vertical axis through the symphysis and correction of medial displacement are difficult to achieve. Access through the greater sciatic notch for palpation and clamp placement is facilitated by the use of prone positioning. 
In a transverse fracture (Fig. 47-15) the inferior (ischiopubic) segment is in one piece, and reduction requires the simultaneous control of the displacement and malrotation of the entire segment. The posterior column usually is the site of greatest fracture displacement, and therefore, the preferred surgical approach is the Kocher–Langenbeck, as described for the posterior wall fracture. As in the posterior column fracture, it is not uncommon to find the superior gluteal neurovascular bundle in close proximity or within the fracture site as it courses through the superior aspect of the greater sciatic notch. The ilioinguinal approach can be considered should the fracture displacement be predominant at the pelvic brim, rather than at the posterior column. 
Technique.
Reduction of a transverse fracture from the posterior approach is similar to the reduction of the posterior column fracture (Table 47-17). Often a number of reduction tools are required. Initially, a Jungbluth clamp alone is sufficient. Reduction of the anterior column can be assessed by palpation of the quadrilateral surface and pelvic brim through the greater sciatic notch. In transtectal and some juxtatectal fractures, only a small portion of the anterior fracture line can be palpated. Intraoperative fluoroscopy may assist in judging the reduction of the anterior column. Residual displacement at the pelvic brim is caused by continued displacement of the fracture around its horizontal axis. Reduction can be completed with the use of a Schanz screw in the ischium or by angle-jawed offset reduction clamps introduced through the greater sciatic notch (Fig. 47-78A, B). Often, all three methods are required (Fig. 47-78C). Occasionally, an angle-jawed offset reduction clamp introduced through the greater sciatic notch is all that is needed (Fig. 47-79). Experience will improve positioning of the reduction screws and the ability to obtain reduction. Lag screw fixation of the anterior column of the transverse fracture is accomplished followed by the application of an accurately contoured neutralization plate, resulting in a biomechanically sound initial internal fixation (Fig. 47-44E). It is important to realize that the anterior column screw can only be placed at a certain angle through the Kocher–Langenbeck approach, which causes it to exit near the pectineal eminence (Fig. 47-80). Although a narrow margin of safety exists for lag screw insertion into the anterior column, 3.5- to 4.5-mm screws can be accommodated in most, if not all, patients.8 
Figure 47-78
Plastic bone model of a transverse fracture showing the positioning of a pointed reduction clamp applied through the greater sciatic notch.
 
A: External view. B: Internal view. C: Plastic bone model showing the use of all three methods—clamp through the greater sciatic notch, clamp between two screws in the retroacetabular surface, and a Schanz screw in the ischium—to accomplish reduction.
 
(A: Copyright Berton R. Moed, MD, St. Louis, MO, and Mark S. Vrahas, MD, Boston, MA; B: From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 817–868; C: From Helfet DL, Bartlett CG, Lorich D. The use of a single limited posterior approach and reduction techniques for specific patterns of acetabular fractures. Op Tech Orthop. 1997;7:196–205. Permission granted.)
A: External view. B: Internal view. C: Plastic bone model showing the use of all three methods—clamp through the greater sciatic notch, clamp between two screws in the retroacetabular surface, and a Schanz screw in the ischium—to accomplish reduction.
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Figure 47-78
Plastic bone model of a transverse fracture showing the positioning of a pointed reduction clamp applied through the greater sciatic notch.
A: External view. B: Internal view. C: Plastic bone model showing the use of all three methods—clamp through the greater sciatic notch, clamp between two screws in the retroacetabular surface, and a Schanz screw in the ischium—to accomplish reduction.
(A: Copyright Berton R. Moed, MD, St. Louis, MO, and Mark S. Vrahas, MD, Boston, MA; B: From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 817–868; C: From Helfet DL, Bartlett CG, Lorich D. The use of a single limited posterior approach and reduction techniques for specific patterns of acetabular fractures. Op Tech Orthop. 1997;7:196–205. Permission granted.)
A: External view. B: Internal view. C: Plastic bone model showing the use of all three methods—clamp through the greater sciatic notch, clamp between two screws in the retroacetabular surface, and a Schanz screw in the ischium—to accomplish reduction.
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Figure 47-79
Intraoperative fluoroscopic view of a transverse type fracture before (A) and after (B) the transverse fracture line was reduced using a reduction clamp applied through the greater sciatic notch.
 
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 817–868.)
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 817–868.)
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Figure 47-79
Intraoperative fluoroscopic view of a transverse type fracture before (A) and after (B) the transverse fracture line was reduced using a reduction clamp applied through the greater sciatic notch.
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 817–868.)
(From Moed BR. Acetabular fractures: Kocher–Langenbeck approach. In: Wiss DA, ed. Master Techniques in Orthopaedic Surgery: Fractures. 3rd ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2012: 817–868.)
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Figure 47-80
Drawing showing the possible angles for insertion of an anterior column lag screw using the Kocher–Langenbeck (K-L) versus the extended iliofemoral (EIF).
 
The angle of the EIF without using this exposure can also be attained by using percutaneous techniques.
 
(Copyright Berton R. Moed, MD.)
The angle of the EIF without using this exposure can also be attained by using percutaneous techniques.
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Figure 47-80
Drawing showing the possible angles for insertion of an anterior column lag screw using the Kocher–Langenbeck (K-L) versus the extended iliofemoral (EIF).
The angle of the EIF without using this exposure can also be attained by using percutaneous techniques.
(Copyright Berton R. Moed, MD.)
The angle of the EIF without using this exposure can also be attained by using percutaneous techniques.
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Table 47-17
ORIF of Transverse Fractures Surgical Steps
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Table 47-17
ORIF of Transverse Fractures Surgical Steps
  •  
    Expose posterior wall and column
  •  
    Protect sciatic nerve
  •  
    Carefully delineate fracture fragments and the fracture line
  •  
    Apply traction to distract the joint using:
    •  
      OR table
    •  
      Universal distractor
    •  
      Manually through a trochanteric Schanz screw
  •  
    Remove any intra-articular debris
  •  
    Reduce femoral head to the intact acetabulum maintaining traction to unload the column fracture fragment(s)
  •  
    Place the appropriate reduction clamp, as required, across the fracture
  •  
    Insert a Schanz screw into the ischium or, alternatively, place a clamp across the fracture through the greater sciatic notch to use in correcting fracture malrotation
  •  
    Reduce the fracture by manipulating the reduction tools
  •  
    Insert a lag screw across the anterior column fracture line
  •  
    If lag screw fixation is not possible, place a short 3.5-mm reconstruction plate across the fracture
  •  
    Neutralize the construct using a well-contoured 3.5-mm reconstruction plate
X
Reduction of a transverse fracture using the ilioinguinal approach is achieved by applying lateral and caudal pressure on the pelvic brim using a ball-spiked pusher through the middle window. The reduction can then be maintained using an angled reduction clamp introduced through the lateral or middle window. Fixation proceeds with screw fixation of the posterior column accomplished through the neutralization plate along the pelvic brim. 
Potential Pitfalls and Preventative Measures.
All the concerns relative to the surgical approach for the posterior wall and posterior column mentioned in Tables 47-10 and 47-13 apply. In addition, one must take great care in exposing the superior aspect of the fracture line at the greater sciatic notch to ensure that the superior gluteal neurovascular bundle is not injured. Residual malrotation of the column fracture is a common problem that cannot be overemphasized. Although it may appear well reduced on its external surface, correction of the malrotation can only be insured by additional assessment of the intrapelvic aspect of the fracture line. This can be accomplished by digital palpation through the greater sciatic notch. As with all acetabular fracture fixations, extra-articular position of all screws should be confirmed using C-arm fluoroscopy before leaving the operating room.29 

Operative Treatment of Associated Acetabular Fracture Types

Open Reduction and Internal Fixation of Posterior Column and Posterior Wall Fractures

Preoperative Planning.
Open reduction and internal fixation of a posterior column and wall fracture requires the implants and instruments previously listed for the individual posterior elementary fracture types (Tables 47-8 and 47-11). These include 3.5-mm malleable reconstruction-type plates, one-third tubular plates, various (1.5-, 2-, 2.7-, 3.5-, and 4.5-mm) cortical screws and 1.5-mm bioabsorbable pegs. Specialized clamps are required for the column reduction and a ball-spike pusher is helpful for subsequent reduction of the posterior wall. 
Positioning and Surgical Approach of Posterior Column and Posterior Wall Fractures.
Patient positioning is similar as that for the individual posterior elementary fracture types. As noted for the posterior column fracture, there are potential advantages of prone positioning: Access through the greater sciatic notch for palpation and clamp placement is facilitated, as is lag screw insertion. With lateral positioning, the weight of the operative leg tends to cause medial displacement of the femoral head with further medial displacement and malrotation of the fractured posterior column fragments. The preferred surgical approach is the Kocher–Langenbeck. 
Technique.
The reduction begins with the posterior column fragment exactly as previously described (Table 47-18). Large posterior wall fractures, however, may contain much of the retroacetabular surface and preclude stable interfragmentary fixation of the column. In this circumstance, a small plate along the border of the greater sciatic notch may be useful in maintaining the reduction of the posterior column. The posterior wall component is then reduced along with any marginal impaction that may be present. Interfragmentary screws in addition to buttress plate fixation are necessary to maintain reduction of the posterior wall (Fig. 47-44F). The buttress plate on the posterior wall will now serve as additional fixation for the posterior column fracture as well. Unless the caudal screws in the plate cross the ischial ramus fracture line, however, the stability of the posterior column is dependent on accurate contouring of the buttress plate and the interfragmentary column screws. Therefore, under bending of the plate, as for an isolated posterior wall, is ill-advised, as it could cause unwanted gapping or translation of the posterior column component. 
 
Table 47-18
ORIF of Posterior Column and Wall Fractures Surgical Steps
  •  
    Expose posterior wall and column
  •  
    Protect sciatic nerve
  •  
    Carefully delineate fracture fragments and the fracture line
  •  
    Apply traction to distract the joint using:
    •  
      OR table
    •  
      Universal distractor
    •  
      Manually through a trochanteric Schanz screw
  •  
    Remove free osteochondral fracture fragments
  •  
    Debride ligamentum teres and any intra-articular debris
  •  
    Identify area(s) of marginal impaction
  •  
    Reduce the column fracture by manipulating the Schanz screw and reduction clamp
  •  
    Insert a lag screw across the fracture
  •  
    If lag screw fixation is not possible, place a short 3.5-mm reconstruction plate across the fracture, avoiding the posterior wall fracture area
  •  
    Using the femoral head as a template:
    •  
      Elevate and reduce marginal impaction
    •  
      Replace and reduce free osteochondral free fragments
    •  
      Temporarily fix fragments with 1.6-mm K-wires, as needed
    •  
      Fill underlying bone void with graft material
    •  
      Replace K-wires with bioabsorbable pegs or miniscrews, as needed
  •  
    Sequentially reduce posterior wall fragments using a ball-spiked pusher
  •  
    Individually fix the wall fragments using lag screws without excessive tightening
  •  
    Buttress and neutralize the construct using a well-contoured 3.5-mm reconstruction plate
  •  
    Insert additional lag screws, as needed
  •  
    Fully tighten all lag screws
X
Potential Pitfalls and Preventative Measures.
All the concerns relative to the surgical approach for the posterior wall mentioned in Table 47-10 apply. In addition, the potential pitfalls and preventative measures for both the elementary posterior wall and elementary posterior column fractures apply (Tables 47-10 and 47-13). 

Open Reduction and Internal Fixation of Transverse and Posterior Wall Fractures

Preoperative Planning.
Open reduction and internal fixation of a transverse and wall fracture requires the implants and instruments previously listed for the individual posterior elementary fracture types (Tables 47-8 and 47-11). These include 3.5-mm malleable reconstruction-type plates, one-third tubular plates, various (1.5-, 2-, 2.7-, 3.5-, and 4.5-mm) cortical screws and 1.5-mm bioabsorbable pegs. Specialized clamps are required for the column reduction and a ball-spike pusher is helpful for subsequent reduction of the posterior wall. In addition, as previously noted for the transverse fracture, extra-long screws (ranging in length from 65-mm to more than 100-mm depending on the screw angle, fracture line location, and patient size) of 3.5 mm, 4.5 mm or possibly 6.5 mm in diameter are required for lag screw fixation of the anterior column fracture line. 
Positioning and Surgical Approach.
Patient positioning is similar as that for the individual posterior elementary fracture types. As noted previously, there are potential advantages of prone positioning. The preferred surgical approach is the Kocher–Langenbeck. For treatment at less than 2 weeks, this approach is usually sufficient (Fig. 47-81A). Otherwise, a more extensive approach may be required (Fig. 47-81B). 
Figure 47-81
 
A: Radiographic appearance at 1 year of the patient whose injury films are seen in Figure 47-26. The fracture was treated within a few days of injury through the Kocher–Langenbeck approach. A short plate was used posteriorly for the transverse component and the anterior column lag screw was inserted percutaneously using C-arm guidance. The comminuted posterior wall was buttressed separately. Also seen is the tip of a retrograde femoral nail. B: Radiographic appearance at 6-year follow-up of the patient whose injury films are shown in Figure 47-41. The fracture was treated 22 days after injury through the extended iliofemoral approach.
 
(Copyright Berton R. Moed, MD.)
A: Radiographic appearance at 1 year of the patient whose injury films are seen in Figure 47-26. The fracture was treated within a few days of injury through the Kocher–Langenbeck approach. A short plate was used posteriorly for the transverse component and the anterior column lag screw was inserted percutaneously using C-arm guidance. The comminuted posterior wall was buttressed separately. Also seen is the tip of a retrograde femoral nail. B: Radiographic appearance at 6-year follow-up of the patient whose injury films are shown in Figure 47-41. The fracture was treated 22 days after injury through the extended iliofemoral approach.
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Figure 47-81
A: Radiographic appearance at 1 year of the patient whose injury films are seen in Figure 47-26. The fracture was treated within a few days of injury through the Kocher–Langenbeck approach. A short plate was used posteriorly for the transverse component and the anterior column lag screw was inserted percutaneously using C-arm guidance. The comminuted posterior wall was buttressed separately. Also seen is the tip of a retrograde femoral nail. B: Radiographic appearance at 6-year follow-up of the patient whose injury films are shown in Figure 47-41. The fracture was treated 22 days after injury through the extended iliofemoral approach.
(Copyright Berton R. Moed, MD.)
A: Radiographic appearance at 1 year of the patient whose injury films are seen in Figure 47-26. The fracture was treated within a few days of injury through the Kocher–Langenbeck approach. A short plate was used posteriorly for the transverse component and the anterior column lag screw was inserted percutaneously using C-arm guidance. The comminuted posterior wall was buttressed separately. Also seen is the tip of a retrograde femoral nail. B: Radiographic appearance at 6-year follow-up of the patient whose injury films are shown in Figure 47-41. The fracture was treated 22 days after injury through the extended iliofemoral approach.
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Technique.
The reduction of the transverse fracture proceeds as previously described (Table 47-19). The addition of a posterior wall component adds technical complexity to the reduction and fixation. The transverse fracture is reduced first and held in place with interfragmentary screw fixation if possible. If the posterior wall fracture is large, sufficient retroacetabular surface may not be available for screw placement. In this circumstance, a small plate adjacent to the posterior border of the innominate bone may suffice (Fig. 47-82). The posterior wall fracture is then reduced in the standard fashion and fixed with interfragmentary screw and plate fixation (Figs. 47-44G and 47-82). Again, minimal undercontouring of the posterior wall plate is desirable; otherwise, the plate may cause a loss of reduction of the transverse fracture line as it is tightened to the bone. 
Figure 47-82
 
A: Three-dimensional CT of a transtectal transverse and posterior wall fracture showing the transverse fracture line (a), a comminuted posterior wall fracture (b), an osteochondral free fragment and an area of marginal impaction (asterisk). B: An intraoperative fluoroscopic image with the patient lateral shows the transverse fracture reduction through a Kocher–Langenbeck approach, obtained using a Farabeuf reduction clamp applied through screws on each side of the fracture in combination with an angle-jawed clamp in the greater sciatic notch and table traction via a trochanteric Schanz screw attached to weights off the end of the OR table. C: Intraoperative fluoroscopic view following clamp removal showing fixation of the transverse fracture component with a short posterior plate and an anterior column lag screw. D: Postoperative AP radiograph showing the final construct after posterior wall lag screw fixation and the application of a plate to buttress the posterior wall and further neutralize the transverse fracture.
 
(Courtesy of Berton R. Moed MD.)
A: Three-dimensional CT of a transtectal transverse and posterior wall fracture showing the transverse fracture line (a), a comminuted posterior wall fracture (b), an osteochondral free fragment and an area of marginal impaction (asterisk). B: An intraoperative fluoroscopic image with the patient lateral shows the transverse fracture reduction through a Kocher–Langenbeck approach, obtained using a Farabeuf reduction clamp applied through screws on each side of the fracture in combination with an angle-jawed clamp in the greater sciatic notch and table traction via a trochanteric Schanz screw attached to weights off the end of the OR table. C: Intraoperative fluoroscopic view following clamp removal showing fixation of the transverse fracture component with a short posterior plate and an anterior column lag screw. D: Postoperative AP radiograph showing the final construct after posterior wall lag screw fixation and the application of a plate to buttress the posterior wall and further neutralize the transverse fracture.
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Figure 47-82
A: Three-dimensional CT of a transtectal transverse and posterior wall fracture showing the transverse fracture line (a), a comminuted posterior wall fracture (b), an osteochondral free fragment and an area of marginal impaction (asterisk). B: An intraoperative fluoroscopic image with the patient lateral shows the transverse fracture reduction through a Kocher–Langenbeck approach, obtained using a Farabeuf reduction clamp applied through screws on each side of the fracture in combination with an angle-jawed clamp in the greater sciatic notch and table traction via a trochanteric Schanz screw attached to weights off the end of the OR table. C: Intraoperative fluoroscopic view following clamp removal showing fixation of the transverse fracture component with a short posterior plate and an anterior column lag screw. D: Postoperative AP radiograph showing the final construct after posterior wall lag screw fixation and the application of a plate to buttress the posterior wall and further neutralize the transverse fracture.
(Courtesy of Berton R. Moed MD.)
A: Three-dimensional CT of a transtectal transverse and posterior wall fracture showing the transverse fracture line (a), a comminuted posterior wall fracture (b), an osteochondral free fragment and an area of marginal impaction (asterisk). B: An intraoperative fluoroscopic image with the patient lateral shows the transverse fracture reduction through a Kocher–Langenbeck approach, obtained using a Farabeuf reduction clamp applied through screws on each side of the fracture in combination with an angle-jawed clamp in the greater sciatic notch and table traction via a trochanteric Schanz screw attached to weights off the end of the OR table. C: Intraoperative fluoroscopic view following clamp removal showing fixation of the transverse fracture component with a short posterior plate and an anterior column lag screw. D: Postoperative AP radiograph showing the final construct after posterior wall lag screw fixation and the application of a plate to buttress the posterior wall and further neutralize the transverse fracture.
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Table 47-19
ORIF of Transverse and Posterior Wall Fractures
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Table 47-19
ORIF of Transverse and Posterior Wall Fractures
  •  
    Expose posterior wall and column
  •  
    Protect sciatic nerve
  •  
    Carefully delineate fracture fragments and the fracture line
  •  
    Apply traction to distract the joint using:
    •  
      OR table
    •  
      Universal distractor
    •  
      Manually through a trochanteric Schanz screw
  •  
    Remove free osteochondral fracture fragments
  •  
    Debride ligamentum teres and any intra-articular debris
  •  
    Identify area(s) of marginal impaction
  •  
    Reduce the transverse fracture using the Schanz screw and/or reduction clamp(s)
  •  
    Insert a lag screw across the fracture into the anterior column
  •  
    If lag screw fixation is not possible, place a short 3.5-mm reconstruction plate across the fracture avoiding the wall fracture area
  •  
    Using the femoral head as a template:
    •  
      Elevate and reduce marginal impaction
    •  
      Replace and reduce free osteochondral free fragments
    •  
      Temporarily fix fragments with 1.6-mm K-wires, as needed
    •  
      Fill underlying bone void with graft material
    •  
      Replace K-wires with bioabsorbable pegs or miniscrews, as needed
  •  
    Sequentially reduce posterior wall fragments using a ball-spiked pusher
  •  
    Individually fix the wall fragments using lag screws without excessive tightening
  •  
    Buttress and neutralize the construct using a well-contoured 3.5-mm reconstruction plate
  •  
    Insert additional lag screws, as needed
  •  
    Fully tighten all lag screws
X
Potential Pitfalls and Preventative Measures.
All the concerns relative to the surgical approach for the posterior wall mentioned in Table 47-10 apply. In addition, the potential pitfalls and preventative measures for both the elementary posterior wall and elementary transverse fractures apply (Tables 47-10 and 47-13), as well as the additional issues noted in the transverse fracture section. 

Open Reduction and Internal Fixation of Anterior Column (or Wall) and Posterior Hemitransverse Fractures

Preoperative Planning.
Preoperative planning for anterior column and posterior hemitransverse fractures is similar to that for the elementary anterior column or wall fracture (Table 47-14). If the main displacement is anterior and the anterior wall is involved, the ball-spiked pusher is often required to assist in holding or correcting malrotation of the fracture fragments. In addition, various sizes of angel-jawed offset reduction forceps may be required to address displaced fractures of the quadrilateral surface (Fig. 47-45A). The Farabeuf and serrated reduction forceps (Fig. 47-45B) are very useful in grasping the displaced anterior column. If the posterior displacement is such that direct manipulation of the posterior is anticipated using a secondary or more extensive surgical approach (see Position and Surgical Approach section), the full assortment of reduction clamps may be required. The standard 3.5-mm implants, including malleable reconstruction-type plates and long 3.5-mm cortical screws, are adequate for fracture fixation. Occasionally, 4.5-mm cortical lag screws inserted at the level of the anterior inferior iliac spine are used for fixation of the anterior column. 
Position and Surgical Approach.
Usually, the posterior column component is only minimally displaced in this fracture type. Therefore, the patient position is supine and the ilioinguinal approach is used. As previously noted, the modified Stoppa approach is a reasonable alternative.4,7,157 If the posterior column is widely displaced (more than 5 mm),4 or it cannot be reduced through the anterior approach, the Kocher–Langenbeck is added, usually in a sequential fashion. Old fractures having early fracture callus and wide displacement, both anteriorly and posteriorly, require a combined or extended surgical approach (Table 47-7). 
Technique.
Once the anterior column/wall reduction is achieved using the previously described techniques, interfragmentary screw fixation from the internal iliac fossa into the sciatic buttress are often initially used, but must be positioned to avoid crossing the fracture line of the unreduced posterior column fracture (Table 47-20). This fixation is supplemented with screw placement between the tables of the ilium at the iliac crest. Alternatively, a plate can be applied across the fracture at the iliac crest, especially if screw placement alone is inadequate. A 3.5-mm reconstruction plate (which can be very slightly under bent to buttress a fractured wall) is added with screws secured into the superior ramus below and the ilium above the wall fracture (Figs. 47-44I and 47-83). Again, these screws are positioned to avoid crossing the fracture line of the unreduced posterior column. In addition, screw holes should be left open for the later insertion through the plate of lag screws directed into the posterior column. As previously noted, the morphology of the pelvic brim varies from patient to patient. The curve of the brim often follows a “J” pattern and the length is usually 13 holes in males and 12 holes in females for most fractures. 
Figure 47-83
Postoperative radiograph of the patient seen in Figure 47-27.
 
The wear defect in the femoral head is again noted. Long-plate fixation along the pelvic brim has been supplemented by a second push plate buttressing the lateral portion of the anterior wall fragments. The posterior hemitransverse is fixed by posterior column screws inserted into the plate applied to the pelvic brim. The joint space is seen to be subtly widened. This appearance may be seen if the anterior wall fragment is slightly over-reduced and causes a partial extrusion of the femoral head. The prognosis for the hip joint is guarded.
The wear defect in the femoral head is again noted. Long-plate fixation along the pelvic brim has been supplemented by a second push plate buttressing the lateral portion of the anterior wall fragments. The posterior hemitransverse is fixed by posterior column screws inserted into the plate applied to the pelvic brim. The joint space is seen to be subtly widened. This appearance may be seen if the anterior wall fragment is slightly over-reduced and causes a partial extrusion of the femoral head. The prognosis for the hip joint is guarded.
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Figure 47-83
Postoperative radiograph of the patient seen in Figure 47-27.
The wear defect in the femoral head is again noted. Long-plate fixation along the pelvic brim has been supplemented by a second push plate buttressing the lateral portion of the anterior wall fragments. The posterior hemitransverse is fixed by posterior column screws inserted into the plate applied to the pelvic brim. The joint space is seen to be subtly widened. This appearance may be seen if the anterior wall fragment is slightly over-reduced and causes a partial extrusion of the femoral head. The prognosis for the hip joint is guarded.
The wear defect in the femoral head is again noted. Long-plate fixation along the pelvic brim has been supplemented by a second push plate buttressing the lateral portion of the anterior wall fragments. The posterior hemitransverse is fixed by posterior column screws inserted into the plate applied to the pelvic brim. The joint space is seen to be subtly widened. This appearance may be seen if the anterior wall fragment is slightly over-reduced and causes a partial extrusion of the femoral head. The prognosis for the hip joint is guarded.
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Table 47-20
ORIF of Anterior Column/Wall and Posterior Hemitransverse Fractures Surgical Steps
  •  
    Determine appropriate surgical approach and whether quadrilateral surface comminution is present
  •  
    Expose anterior wall and column
  •  
    Carefully clear the fracture lines of debris
  •  
    Apply traction to unload the joint using:
    •  
      OR table
    •  
      Manually through a trochanteric Schanz screw
  •  
    Reduce femoral head to remaining intact acetabulum
  •  
    Correct fracture translation and malrotation using appropriate reduction instruments
  •  
    Fix fractured column or wall using lag screws
  •  
    Buttress any quadrilateral surface comminution, as required
    •  
      Use middle window of the ilioinguinal approach
    •  
      Use modified Stoppa extension of medial window of the ilioinguinal approach
    •  
      Select modified Stoppa approach for the surgery
  •  
    Apply a well-contoured 3.5-mm reconstruction plate along the pelvic brim being careful not to place screws across the posterior column fracture line
  •  
    Place the appropriate clamp to reduce the posterior column fracture
  •  
    Insert a lag screw across the posterior column fracture, preferably through the plate
  •  
    Insert additional screws and lag screws, as deemed necessary
X
The posterior column fracture may now be reduced using an angled clamp placed around the iliopsoas from the quadrilateral surface portion of the posterior column fragment to the supra-acetabular ilium, as in Figure 47-72. An intrapelvic rotational reduction of the posterior column is achieved. The reduction is assessed by palpation of the quadrilateral surface and image-intensifier visualization of the ilioischial line on the AP view. It is important to recognize that the reduction of the articular surface is never directly visualized. By anatomically reducing the internal contour of the innominate bone in combination with intraoperative fluoroscopy, an anatomic reduction of the articular surface is obtained. The posterior column fracture is usually fixed with screws inserted from the internal iliac fossa, through the plate, and directed down the length of the posterior column to exit the ischium or lesser sciatic notch (Figs. 47-44I and 47-83). A percutaneous screw placed from the outer cortex of the ilium to the ischial spine can be used as an alternative or as supplemental fixation (Fig. 47-84). As noted above, when the posterior column cannot be adequately reduced or fixed through the anterior approach, a second, posterior approach should be undertaken at this point. This requires patient repositioning with the surgical approach and fixation as described for the elementary posterior column (Table 47-12). 
Figure 47-84
Model showing the path for a screw inserted into the posterior column from the external surface of the ilium.
 
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 35, page 57. Copyright Joe Allred. Permission granted.)
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 35, page 57. Copyright Joe Allred. Permission granted.)
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Figure 47-84
Model showing the path for a screw inserted into the posterior column from the external surface of the ilium.
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 35, page 57. Copyright Joe Allred. Permission granted.)
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 35, page 57. Copyright Joe Allred. Permission granted.)
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In many cases, screws alone may be used for fixation of the anterior column and posterior hemitransverse fracture. However, plates along the pelvic brim should be added for comminuted fractures or osteopenic patients. Anterior wall fracture components may require additional buttress plate fixation (Fig. 47-83). 
Potential Pitfalls and Preventative Measures.
All the concerns relative to the selected anterior or posterior surgical approach apply (Tables 47-10 and 47-16). In addition, the potential pitfalls and preventative measures for the elementary anterior column and wall fractures apply (Table 47-16). Furthermore, after reduction of the exposed anterior fracture, one must be very careful not to inadvertently cross the fracture line of the unreduced posterior column. Other pitfalls concern potential inadequate reduction and/or fixation of the posterior column. If the posterior column cannot be anatomically reduced and/or stable fixation cannot be obtained, a secondary posterior approach should be performed to attain these objectives. 

Open Reduction and Internal Fixation of T-Shaped Fractures

Preoperative Planning.
A major step in the preoperative planning process for the T-shaped fracture is determining the appropriate surgical approach (Table 47-7). Since the T-shaped fracture is most commonly operated on using the Kocher–Langenbeck approach, the preoperative planning checklist is similar to that for transverse fractures and posterior column fractures (Table 47-11). As with the transverse fracture, standard 3.5-mm hardware, including malleable reconstruction-type plates and 3.5-mm cortical screws are required. Cortical 4.5-mm cortical screws may also be required to serve as anchor points for reduction clamps or as a lag screw across the column fracture. In addition, extra-long screws (ranging in length from 65 mm to more than 100 mm depending on the screw angle, fracture line location, and patient size) of 3.5 mm, 4.5 mm, or possibly 6.5 mm in diameter are required for lag screw fixation of the anterior column. On occasion, an anterior (ilioinguinal or modified Stoppa) approach may be chosen for the reduction and fixation of the T-shaped fracture. In this situation Table 47-14 would apply and long 3.5-mm screws are needed for lag screw fixation of the posterior column. 
Position and Surgical Approach.
The T-shaped fracture is most often operated on through the Kocher–Langenbeck approach with the patient in the prone position (Table 47-7). If the anterior column fracture cannot be reduced through the selected posterior approach, a subsequent patient repositioning and an anterior approach is required. As previously noted, an anterior (ilioinguinal or modified Stoppa) approach is an option for the reduction and fixation of the T-shaped fracture. The conditions under which this selection is most common when the stem of the T is anterior, close to the pelvic brim. This configuration typically leaves a large portion of the quadrilateral surface intact to the posterior column fragment, allowing the surgeon sufficient access for the reduction. Analogous to the situation just described, if the reduction of the posterior column is not successful through the anterior approach, a staged subsequent Kocher–Langenbeck is required for the direct reduction and fixation of the posterior column. 
T-shaped fractures with significant displacement of the vertical stem at the obturator notch are very unlikely to be reduced with a single nonextensile approach and are best treated initially through an extended approach or a combination of approaches that allows simultaneous access to both columns. Alternatively, planned sequential posterior and anterior approaches may be used. Old fractures having fracture callus and those with the transverse fracture line through the weight-bearing dome (transtectal) require an extended approach (Table 47-7).93 
Technique.
After the posterior column has been exposed and the fracture site cleared of debris, attention is directed to the anterior column reduction (Table 47-21). The reduction of the anterior column fracture is performed by displacing the posterior column fracture and placing a clamp across the stem of the T between the anterior column fracture and the intact ilium, as in Figure 47-78A, B. The reduction is assessed radiographically as well as directly visualized on the articular surface with the femoral head distracted. A circumferential capsulotomy distal to the labrum of variable length may be required to facilitate the visual inspection. Internal fixation with lag screws down the long axis of the anterior column is performed. Again, it is important to realize that the anterior column screw can only be placed at a certain angle through the Kocher–Langenbeck approach, which causes it to exit near the pectineal eminence (Fig. 47-80). However, a very long screw traversing almost the entire anterior column can be inserted, approximating the angle capable through the extended iliofemoral approach, by using a percutaneous insertion point and fluoroscopic directional guidance (Fig. 47-85). The posterior column fracture is then reduced and internally fixed as described in the posterior column section (Fig. 47-86). Another option is the reduction and lag screw fixation of the posterior column fracture first. This is made more complicated by the need to keep the posterior column fixation completely out of the anterior column fracture and the stem of the T. Placement of clamps through the greater sciatic notch then allows reduction of the anterior column fracture. With either of these techniques, if the anterior column fracture cannot be reduced, a subsequent anterior approach may be required. 
Figure 47-85
Model showing the path for a screw inserted into the anterior column from the external surface of the ilium.
 
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 29, page 49. Copyright Joe Allred. Permission granted.)
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 29, page 49. Copyright Joe Allred. Permission granted.)
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Figure 47-85
Model showing the path for a screw inserted into the anterior column from the external surface of the ilium.
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 29, page 49. Copyright Joe Allred. Permission granted.)
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 29, page 49. Copyright Joe Allred. Permission granted.)
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X
Figure 47-86
Radiographic appearance at 2 years of the patient whose injury films are seen in Figure 47-29.
 
This patient was treated in the prone position through the Kocher–Langenbeck approach. Because of the patient’s large size, two lag screws were placed into the anterior column and two plates were applied to the posterior column.
 
(Copyright Berton R. Moed, MD.)
This patient was treated in the prone position through the Kocher–Langenbeck approach. Because of the patient’s large size, two lag screws were placed into the anterior column and two plates were applied to the posterior column.
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Figure 47-86
Radiographic appearance at 2 years of the patient whose injury films are seen in Figure 47-29.
This patient was treated in the prone position through the Kocher–Langenbeck approach. Because of the patient’s large size, two lag screws were placed into the anterior column and two plates were applied to the posterior column.
(Copyright Berton R. Moed, MD.)
This patient was treated in the prone position through the Kocher–Langenbeck approach. Because of the patient’s large size, two lag screws were placed into the anterior column and two plates were applied to the posterior column.
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Table 47-21
ORIF of T-Shaped Fractures via the Posterior Approach Surgical Steps
  •  
    Expose posterior wall and column
  •  
    Protect sciatic nerve
  •  
    Carefully delineate fracture fragments and the fracture line
  •  
    Apply traction to distract the joint using:
    •  
      OR table
    •  
      Universal distractor
    •  
      Manually through a trochanteric Schanz screw
  •  
    Remove any intra-articular debris
  •  
    Reduce femoral head to the intact acetabulum maintaining traction to unload the column fracture fragment(s)
  •  
    Displace the posterior column fracture to allow clamp placement for reduction of the anterior column fracture
  •  
    Inspect the fracture radiographically as well as visually to determine adequacy of the reduction. Perform a circumferential capsulotomy distal to the labrum, as required, to facilitate the visual inspection
  •  
    Insert a long screw from the ilium into the anterior column
  •  
    Insert a Schanz screw into the ischium to use in correcting posterior column malrotation
  •  
    Reduce the fracture by manipulating the Schanz screw and a reduction clamp
  •  
    Insert a lag screw across the posterior column fracture line
  •  
    If lag screw fixation is not possible, place a short 3.5-mm reconstruction plate across the fracture
  •  
    Neutralize the construct using a well-contoured 3.5-mm reconstruction plate
X
If the reduction can be achieved through the Kocher–Langenbeck approach alone, direct plate fixation on both columns is not necessary. A single well-contoured plate on the retroacetabular surface with lag screws across both the anterior and posterior column fractures can suffice (Fig. 47-44H).164 
The presence of a posterior wall component adds significant complexity to the fracture reduction. Stable fixation of the posterior column and wall without crossing into the stem of the T or the anterior column fracture line may no longer be possible. Therefore, the anterior column fracture must be reduced and fixed first. Unfortunately, the ideal starting point for the anterior column lag screws is often obscured by the posterior wall fracture. Obtaining reduction and fixation of the anterior column first through either an anterior approach or through the extended approach makes the reduction and fixation of the posterior column and wall more feasible. However, it is very difficult to obtain stable fixation of the anterior column fracture without the screws inadvertently crossing the stem of the T, the posterior column fracture line, or the posterior wall fracture or penetrating the hip joint. These technical considerations may explain why the T-shaped fracture with an associated posterior wall had the lowest rate of excellent reductions of any type or subtype of fractures in the series of Letournel and Matta and colleagues.93,107 
Potential Pitfalls and Preventative Measures.
All the concerns relative to the selected anterior or posterior surgical approach apply (Tables 47-10, 47-16, and 47-22). In addition, a major potential pitfall is selection of the wrong surgical approach. If the column opposite to the selected surgical approach cannot be adequately mobilized and reduced, the decision should be made quickly to alter the surgical tactic and plan to proceed to a second incision, directly exposing the opposite column. Care should be exercised to ensure that any inserted fixation does not cross into the unreduced opposite column or the vertical limb of the T. Should the issue be that early callus formation precludes fracture mobilization, consideration should be made for proceeding directly to an extensile approach. 
Table 47-22
ORIF of T-Shaped Fractures Additional Potential Pitfalls and Preventions
Pitfall Preventions
1. Selection of the wrong surgical approach Quickly recognize the inability to reduce and/or fix the column opposite to the surgical approach
Reduce and fix the exposed column
Ensure that inserted hardware does not compromise the vertical limb of the T or enter the unreduced opposite column
To address the opposite column using a second incision or converting to an extensile approach
2. Traction injury to the sciatic nerve during retraction of the posterior column Avoid prolonged and excessive retraction of the sciatic nerve while manipulating the anterior column through the greater sciatic notch using the posterior approach
Avoid prolonged and excessive retraction of the sciatic nerve while inserting retractors into, or manipulating the posterior column, through the greater sciatic notch using the anterior approach
3. Unstable fixation of the column opposite to the surgical approach Exposure of the opposite column and application of a neutralization plate
4. Inability to fix the anterior column from the posterior approach because of an associated posterior wall fracture Recognize the situation preoperatively
Plan anterior column fixation from the Kocher–Langenbeck approach that will avoid the posterior wall fracture bed
Alternatively, plan to fix one column first without compromising reduction of the other column, then proceeding to fix the other column using a second approach
If a problem occurs intraoperatively, be ready to proceed to a second or extensile approach
X
Usually, the reduction of the anterior column fracture is performed by displacing the posterior column fracture and placing a clamp across the stem of the T between the anterior column fracture and the intact ilium. During this maneuver, great care must be exercised not to put excessive stretch on the sciatic nerve. Inability to obtain secure fixation of the reduced opposite column, such as because of inadequate screw purchase in osteopenic bone, should also be addressed by a second incision and direct application of plate fixation. The presence of a posterior wall fracture requiring fixation as a component of the T-shaped fracture indicates a higher level of difficulty. In this situation one must carefully plan fixation location and be prepared to convert to an alternative surgical approach. 

Open Reduction and Internal Fixation of Both-Column Fractures

Preoperative Planning.
A major step in the preoperative planning process for the both-column fracture is determining the appropriate surgical approach (Table 47-7). Since the both-column fracture is most commonly operated on using an anterior approach (ilioinguinal or modified Stoppa), the preoperative planning checklist is similar to that for anterior column and wall fractures (Table 47-14). For those fractures requiring an alternative approach, the checklist is similar to that for the posterior column (Table 47-11). As for the transverse fracture types, long screws are often required. 
Position and Surgical Approach.
The both-column fracture is most commonly operated on using an anterior approach (ilioinguinal or modified Stoppa) with the patient supine. The presence of a posterior wall component does not preclude the use of this approach. If the posterior wall has a large superior spike of ilium attached, it can be reduced by additional lateral dissection of the ilium from the crest incision (Fig. 47-87). In addition, if the posterior wall labrum has not been torn, the wall will reduce along with the reduction of the posterior column. It can be fixed with screws from the inner table directed into the posterior superior wall. If this is not successful, a second, posterior approach can be added to address the wall. 
Figure 47-87
The patient whose injury films are seen in Figure 47-31 who was treated through the ilioinguinal approach.
 
A: Fluoroscopic image showing intraoperative reduction of a large posterior wall component using a clamp with one tine placed on the iliac spike of the wall fracture by additional dissection on the outer table of the ilium. B: Radiographic appearance at 2 years showing obliquely oriented screws that were placed from just lateral to the pelvic brim and directed posteriorly toward the superior iliac extension of the posterior wall fragment.
 
(Copyright Berton R. Moed, MD.)
A: Fluoroscopic image showing intraoperative reduction of a large posterior wall component using a clamp with one tine placed on the iliac spike of the wall fracture by additional dissection on the outer table of the ilium. B: Radiographic appearance at 2 years showing obliquely oriented screws that were placed from just lateral to the pelvic brim and directed posteriorly toward the superior iliac extension of the posterior wall fragment.
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Figure 47-87
The patient whose injury films are seen in Figure 47-31 who was treated through the ilioinguinal approach.
A: Fluoroscopic image showing intraoperative reduction of a large posterior wall component using a clamp with one tine placed on the iliac spike of the wall fracture by additional dissection on the outer table of the ilium. B: Radiographic appearance at 2 years showing obliquely oriented screws that were placed from just lateral to the pelvic brim and directed posteriorly toward the superior iliac extension of the posterior wall fragment.
(Copyright Berton R. Moed, MD.)
A: Fluoroscopic image showing intraoperative reduction of a large posterior wall component using a clamp with one tine placed on the iliac spike of the wall fracture by additional dissection on the outer table of the ilium. B: Radiographic appearance at 2 years showing obliquely oriented screws that were placed from just lateral to the pelvic brim and directed posteriorly toward the superior iliac extension of the posterior wall fragment.
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An extensile approach with the patient in the lateral position should be selected when fracture callus is present (i.e., surgery delayed more than 2 weeks following injury) that impairs fracture mobilization. Other situations include those both-column injuries having a comminuted fracture of the posterior column, a small or comminuted posterior wall fracture, a displaced fracture line involving the sacroiliac joint, or a wide separation of the anterior and posterior columns at the rim of the acetabulum.107 
Technique.
Reduction and fixation of the both-column fracture through the ilioinguinal approach is frequently similar to that of the anterior and posterior hemitransverse fracture (Table 47-23). Attention is first directed to reducing and fixing the anterior column to the remaining intact ilium. An intercalary triangular-free fragment of iliac crest is often present. This fragment is first fixed to the intact ilium with a lag screw and the remainder of the anterior column then follows using a lag screw or a short 3.5-mm plate (Fig. 47-44J). The entire internal contour of the innominate bone must be reconstructed to ensure anatomic reduction of the acetabulum. Comminution or plastic deformation of the thin cortical bone of the internal iliac fossa is common, making assessment of reduction impossible in this location. Frequently, comminution at the pelvic brim is seen, and if this is not reduced, the anterior column reduction can be assessed only at the iliac crest. The tendency, then, is for the surgeon to leave the anterior column with a residual flexion and adduction deformity, making perfect reduction of the joint impossible. As with operatively treated both-column fractures, operative malreduction may lead to secondary surgical congruence if all the fracture fragments remain congruent to the femoral head. Although this may be better tolerated than other malreductions of the acetabulum, it is still undesirable. A posterior wall component, if present, can be addressed by developing the exposure to the lateral surface of the ilium.53 A large reduction clamp placed across the anterior border of the innominate bone can be used to reduce the posterior wall (Fig. 47-87A). This fracture can be fixed with obliquely oriented screws placed from just lateral to the pelvic brim and directed posteriorly toward the superior iliac extension of the wall fragment (Fig. 47-87B). 
Table 47-23
ORIF of the Both-Column Fracture via the Ilioinguinal Approach Surgical Steps
  •  
    Expose anterior wall and column
  •  
    Carefully clear the fracture lines of debris
  •  
    Apply traction to unload the joint using:
    •  
      OR table
    •  
      Manually through a trochanteric Schanz screw
  •  
    Reduce femoral head to remaining intact acetabulum
  •  
    Correct fracture translation and malrotation using appropriate reduction instruments
  •  
    Sequentially reduce and fix the fractured anterior column using lag screws or short plates
  •  
    Reduce and stabilize any associated large posterior wall fracture
  •  
    Apply a well-contoured 3.5-mm reconstruction plate along the pelvic brim being careful not to place screws across the posterior column fracture line
  •  
    Place the appropriate clamp to reduce the posterior column fracture
    •  
      Use lateral window of the ilioinguinal approach
    •  
      Use middle window of the ilioinguinal approach
    •  
      Use modified Stoppa extension of medial window of the ilioinguinal approach
  •  
    Insert a lag screw across the posterior column fracture, preferably through the plate
  •  
    Insert additional screws and lag screws, as deemed necessary
X
Frequently, impacted areas of articular cartilage are encountered. This is especially frequent with initial medial displacements of the femoral head causing an impaction of the medial roof. Lateral traction via a trochanteric pin may be used to position the femoral head beneath the intact segment of articular surface. The femoral head may then be used as a mold for the reduction of the impacted segments. The disimpaction of such fragments is usually performed through the anterior column or quadrilateral surface fracture lines. In some circumstances, the impacted roof fragment may not be accessible through a primary fracture line and a cortical window may have to be created in the internal iliac fossa, allowing the insertion of a bone tamp and disimpaction of the fragment with radiographic assessment of the reduction. When roof impaction is reduced, screw fixation just above the fragment may help to prevent reimpaction during healing (Fig. 47-88). These screws are naturally close to the articular surface and, if displacement does occur, may come in contact with the femoral head, contributing to articular wear and loss of the joint. 
Figure 47-88
Six-month radiograph of the patient seen in Figure 47-28.
 
The “gull wing” impacted fragment has been reduced using the femoral head as a template. A lag screw placed from outside the bone to the quadrilateral surface passes directly above the fragment to buttress it, and a second anteroposterior screw is placed just above this fragment to prevent the first screw from losing fixation and allowing displacement of the fragment. A slight imperfection in the roof can be appreciated where the impacted fragment was reduced.
The “gull wing” impacted fragment has been reduced using the femoral head as a template. A lag screw placed from outside the bone to the quadrilateral surface passes directly above the fragment to buttress it, and a second anteroposterior screw is placed just above this fragment to prevent the first screw from losing fixation and allowing displacement of the fragment. A slight imperfection in the roof can be appreciated where the impacted fragment was reduced.
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Figure 47-88
Six-month radiograph of the patient seen in Figure 47-28.
The “gull wing” impacted fragment has been reduced using the femoral head as a template. A lag screw placed from outside the bone to the quadrilateral surface passes directly above the fragment to buttress it, and a second anteroposterior screw is placed just above this fragment to prevent the first screw from losing fixation and allowing displacement of the fragment. A slight imperfection in the roof can be appreciated where the impacted fragment was reduced.
The “gull wing” impacted fragment has been reduced using the femoral head as a template. A lag screw placed from outside the bone to the quadrilateral surface passes directly above the fragment to buttress it, and a second anteroposterior screw is placed just above this fragment to prevent the first screw from losing fixation and allowing displacement of the fragment. A slight imperfection in the roof can be appreciated where the impacted fragment was reduced.
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X
Following reduction of the anterior column and all its components, the posterior column is reduced using a clamp placed through the lateral or middle window of the ilioinguinal approach (Fig. 47-72). Direct reduction is also possible through the modified Stoppa approach. As with the anterior and posterior hemitransverse fracture, the posterior column fracture is usually fixed with screws inserted from the internal iliac fossa, through a long contoured plate applied along the pelvic brim, and directed down the length of the posterior column to exit the ischium or lesser sciatic notch (Figs. 47-44J and 47-87B). A percutaneous screw placed from the outer cortex of the ilium to the ischial spine can be used as an alternative or as supplemental fixation (Fig. 47-84). Many both-column fractures may be amenable to lag screw fixation alone. However, a plate applied to the pelvic brim adds additional stability and should always be used if there is any question regarding the stability of the screw-only construct. 
For fractures that require an extensile approach, the sequence of reduction and fixation is usually similar to that using the ilioinguinal approach. First, the anterior column is reduced to the remaining intact ilium and fixed with lag screws. The posterior column fracture fragment is then reduced and stabilized. If there is a remaining separate component, it is now reduced to the columns. The entire construct is then stabilized using 3.5-mm reconstruction plates (Fig. 47-44K). 
Potential Pitfalls and Preventative Measures.
All the concerns relative to the selected anterior surgical approach apply (Table 47-16). In addition, a major potential pitfall is selection of the wrong surgical approach. If the posterior column or a posterior wall component cannot be adequately mobilized and reduced, the decision should be made quickly to proceed to a second incision, for direct exposure and posterior column reduction. As with the T-shaped fracture, care should be exercised to ensure that any inserted fixation does not cross into the unreduced posterior wall or column. Should the issue be that early callus formation precludes fracture mobilization, the anterior approach should be aborted in favor of an extensile approach. 

Percutaneous Operative Treatment of Acetabular Fractures

Indications/Contraindications

Percutaneous fixation, with or without closed reduction, has been proposed to prevent potential further fracture displacement and for elderly patients with displaced acetabular fractures in whom a less than anatomic reduction could be accepted, as well as for simple fractures with minimal displacements, and for the morbidly obese.40,46,66,116,121,137 Percutaneous fixation has also been proposed as an adjunct to standard open reduction and internal fixation techniques (Figs. 47-84 and 47-85).34,169 In addition, it has been offered as an option in conjunction with limited open surgery for displaced fractures in the elderly as a staging procedure for total hip arthroplasty and in young patients with severe injuries that prevent formal open reduction and internal fixation of the fracture.35,160,168 The potential benefits of percutaneous surgery are self-evident. However, specific indications and contraindications for the use of this technique are still being formulated.10,160 
The main proponents recommend that all nondisplaced fractures are amenable to percutaneous treatment, with the exception of those having an unstable posterior wall fracture component.10 At issue is how to determine which nondisplaced fractures are at risk to displace and, therefore, warrant any surgery at all. As previously noted, only a very small number (less than 7%) of these nondisplaced and minimally displaced fractures are potentially unstable and will significantly displace.183 Displaced fractures generally amenable to percutaneous treatment include anterior wall, anterior column, and transverse types.10 Anterior column and posterior hemitransverse, T-shaped, and both-column fractures can be treated percutaneously; however, this treatment is best reserved for the geriatric population, having minimal posterior column displacement.10,48,49 A displaced or unstable posterior wall component is a contraindication for percutaneous treatment.10 Impacted acetabular dome fragments and quadrilateral surface involvement cannot be addressed percutaneously. 
Preoperative Planning.
If percutaneous treatment is to be used, one must fully understand the surgical objectives (Table 47-24). When the decision has been made to operate on a nondisplaced fracture, the objective is to insert screws into the appropriate column(s). Displaced fractures require fracture reduction that commonly is less than anatomic. The reduction may be accomplished by closed manipulation, but may involve a “mini-open” technique, which requires specialized reduction tools (Fig. 47-89). Fixation is usually provided by 6.5-mm cannulated screws.10 Extra-long guidewires for these screws may be required. If fracture reduction is to be performed, timing of surgery is important. Surgery is best performed as soon as possible and is usually performed within 1 week of injury.10,48 
Figure 47-89
Examples of various instruments required for “Mini-open” percutaneous treatment.
 
Top row, left to right: Collinear clamp (Synthes, USA), large pointed reduction forceps, Reinert reduction clamp with paddle, and Reinert reduction clamp with ball-spike. Middle row, left to right: Angled “pigsticker,” straight “pigsticker,” Cobb elevator, ball-spiked pusher, and collinear clamp (Smith & Nephew, USA). Bottom: “Rib-tickler” device.
 
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 74, page 151. Copyright Joe Allred. Permission granted.)
Top row, left to right: Collinear clamp (Synthes, USA), large pointed reduction forceps, Reinert reduction clamp with paddle, and Reinert reduction clamp with ball-spike. Middle row, left to right: Angled “pigsticker,” straight “pigsticker,” Cobb elevator, ball-spiked pusher, and collinear clamp (Smith & Nephew, USA). Bottom: “Rib-tickler” device.
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Figure 47-89
Examples of various instruments required for “Mini-open” percutaneous treatment.
Top row, left to right: Collinear clamp (Synthes, USA), large pointed reduction forceps, Reinert reduction clamp with paddle, and Reinert reduction clamp with ball-spike. Middle row, left to right: Angled “pigsticker,” straight “pigsticker,” Cobb elevator, ball-spiked pusher, and collinear clamp (Smith & Nephew, USA). Bottom: “Rib-tickler” device.
(From: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Figure 74, page 151. Copyright Joe Allred. Permission granted.)
Top row, left to right: Collinear clamp (Synthes, USA), large pointed reduction forceps, Reinert reduction clamp with paddle, and Reinert reduction clamp with ball-spike. Middle row, left to right: Angled “pigsticker,” straight “pigsticker,” Cobb elevator, ball-spiked pusher, and collinear clamp (Smith & Nephew, USA). Bottom: “Rib-tickler” device.
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Table 47-24
Percutaneous Fixation of Acetabular Fractures Preoperative Planning Checklist
  •  
    OR Table: Standard radiolucent table
  •  
    Position: Supine
  •  
    Fluoroscopy location: Opposite to the side of the operating surgeon
  •  
    Equipment: Purpose-specific and custom reduction clamps
    •  
      K-wires for temporary fixation
    •  
      Oscillating drill
  •  
    Implants: Standard and long 6.5-mm partially threaded screws
X
Technique.
The patient is placed supine on a radiolucent operating room table (Table 47-25). The entire lower abdomen and the leg ipsilateral to the fracture are draped free to allow manipulative reduction maneuvers.167 The C-arm fluoroscopy unit is positioned opposite to the side of the fracture. There is no single maneuver to effect fracture reduction. Using fluoroscopic imaging to assess reduction, various maneuvers are tried, including in-line traction, internal and external hip rotation, and hip abduction.10,167 However, the majority of cases will require a mini-opening with application of specialized reduction clamps (Fig. 47-90). This “mini-open” exposure involves limited exposure through the lateral window of the ilioinguinal incision. Following the reduction, column screws are inserted percutaneously directed by fluoroscopic imaging (Fig. 47-90). Variations of the standard radiographic views are used fluoroscopically to ensure the correct trajectory for a screw placement, such as the obturator outlet view and the inlet iliac view for those inserted antegrade into anterior column, as well as the teardrop view (Fig. 47-91).167 
Figure 47-90
Juxtatectal transverse fracture with main displacement anterior in a 47-year-old laborer who fell from a roof.
 
A: Preoperative fluoroscopic AP view. B: Intraoperative fluoroscopic AP view showing the inserted Reinert reduction clamp with ball-spike having the inner tine on the anterior column and the outer (lateral) tine on the gluteus medius ridge after effecting a reduction. A guidewire for the cannulated screw is being inserted using a straight “pigsticker.” C: Clinical photo showing the inner tine of the clamp inserted through the lateral “mini-open” limited incision and the lateral tine poked through a stab wound to access the gluteus medius ridge. D: Intraoperative fluoroscopic obturator outlet view showing the anterior column screw insertion. E: Three-month postoperative AP radiograph showing the anatomic reduction.
 
(From Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher (IBSN 978-1-4507-3105-8); 2010, Figure 78, page 155 and case 15, pages 162, 163, and 164. Copyright Joe Allred. Permission granted.)
A: Preoperative fluoroscopic AP view. B: Intraoperative fluoroscopic AP view showing the inserted Reinert reduction clamp with ball-spike having the inner tine on the anterior column and the outer (lateral) tine on the gluteus medius ridge after effecting a reduction. A guidewire for the cannulated screw is being inserted using a straight “pigsticker.” C: Clinical photo showing the inner tine of the clamp inserted through the lateral “mini-open” limited incision and the lateral tine poked through a stab wound to access the gluteus medius ridge. D: Intraoperative fluoroscopic obturator outlet view showing the anterior column screw insertion. E: Three-month postoperative AP radiograph showing the anatomic reduction.
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Figure 47-90
Juxtatectal transverse fracture with main displacement anterior in a 47-year-old laborer who fell from a roof.
A: Preoperative fluoroscopic AP view. B: Intraoperative fluoroscopic AP view showing the inserted Reinert reduction clamp with ball-spike having the inner tine on the anterior column and the outer (lateral) tine on the gluteus medius ridge after effecting a reduction. A guidewire for the cannulated screw is being inserted using a straight “pigsticker.” C: Clinical photo showing the inner tine of the clamp inserted through the lateral “mini-open” limited incision and the lateral tine poked through a stab wound to access the gluteus medius ridge. D: Intraoperative fluoroscopic obturator outlet view showing the anterior column screw insertion. E: Three-month postoperative AP radiograph showing the anatomic reduction.
(From Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher (IBSN 978-1-4507-3105-8); 2010, Figure 78, page 155 and case 15, pages 162, 163, and 164. Copyright Joe Allred. Permission granted.)
A: Preoperative fluoroscopic AP view. B: Intraoperative fluoroscopic AP view showing the inserted Reinert reduction clamp with ball-spike having the inner tine on the anterior column and the outer (lateral) tine on the gluteus medius ridge after effecting a reduction. A guidewire for the cannulated screw is being inserted using a straight “pigsticker.” C: Clinical photo showing the inner tine of the clamp inserted through the lateral “mini-open” limited incision and the lateral tine poked through a stab wound to access the gluteus medius ridge. D: Intraoperative fluoroscopic obturator outlet view showing the anterior column screw insertion. E: Three-month postoperative AP radiograph showing the anatomic reduction.
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Figure 47-91
 
A: Teardrop view obtained to show the long column of bone running from the anterior superior iliac spine to the posterior superior iliac spine, which is available for anterior column and wall lag screw fixation. An instrument laid over the skin marks the point for percutaneous screw insertion. B: Photo showing the patient and C-arm position. To obtain the teardrop view, the fluoro is rotated inferiorly (outlet angulation) and toward the side of interest (obturator angulation) from the AP view
 
(A: From Figure 33, page 55; Copyright Joe Allred and B: From Figure 17, page 33; Copyright Aaron Allred; from: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010. Permission granted.)
A: Teardrop view obtained to show the long column of bone running from the anterior superior iliac spine to the posterior superior iliac spine, which is available for anterior column and wall lag screw fixation. An instrument laid over the skin marks the point for percutaneous screw insertion. B: Photo showing the patient and C-arm position. To obtain the teardrop view, the fluoro is rotated inferiorly (outlet angulation) and toward the side of interest (obturator angulation) from the AP view
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Figure 47-91
A: Teardrop view obtained to show the long column of bone running from the anterior superior iliac spine to the posterior superior iliac spine, which is available for anterior column and wall lag screw fixation. An instrument laid over the skin marks the point for percutaneous screw insertion. B: Photo showing the patient and C-arm position. To obtain the teardrop view, the fluoro is rotated inferiorly (outlet angulation) and toward the side of interest (obturator angulation) from the AP view
(A: From Figure 33, page 55; Copyright Joe Allred and B: From Figure 17, page 33; Copyright Aaron Allred; from: Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010. Permission granted.)
A: Teardrop view obtained to show the long column of bone running from the anterior superior iliac spine to the posterior superior iliac spine, which is available for anterior column and wall lag screw fixation. An instrument laid over the skin marks the point for percutaneous screw insertion. B: Photo showing the patient and C-arm position. To obtain the teardrop view, the fluoro is rotated inferiorly (outlet angulation) and toward the side of interest (obturator angulation) from the AP view
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Table 47-25
Percutaneous Fixation of Acetabular Fractures Surgical Steps
  •  
    Place supine of the radiolucent OR table
  •  
    Check with C-arm fluoroscopy that adequate imaging of the fracture is possible
  •  
    Prepare and drape the patient to allow free manipulation of the limb and allow “mini-open” exposure, if required
  •  
    Manipulate the limb under fluoroscopic observation
  •  
    If closed manipulation fails, proceed to using reduction instruments via a “mini-open” approach
  •  
    Sequentially reduce the fracture, basically going from anterior to posterior
  •  
    Fix with cannulated 6.5-mm screws lag screws inserted over guidewires
  •  
    Remove all provisional fixation
  •  
    Assess reduction and fixation using fluoroscopy
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Potential Pitfalls and Preventative Measures.
The main pitfall of percutaneous treatment is poor patient selection. One should have a clear understanding of the capabilities of this technique. Anatomic reduction of minimally displaced fractures is possible using limited open reduction in the experienced surgeon’s hands (Fig. 47-90). However, anatomic reduction of displaced fractures is not commonly attainable, nor is it necessarily the treatment objective (Fig. 47-92). The concept is that less than adequate reductions in the elderly patient population (aged 60 and older) treated percutaneously attain outcomes equivalent to those treated by open reduction and internal fixation, as well as acute total hip arthroplasty.10,48,49 
Figure 47-92
Both-column fracture in a 72-year-old man struck by a car.
 
A: AP injury radiograph. B: AP 3-month follow-up radiograph. A loss of reduction with loss of fixation and medialization of the femoral head is evident. Despite the poor radiologic outcome, the patient remained essentially pain-free and active.
 
(From Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Case 17, pages 169 and 175. Copyright Joe Allred. Permission granted.)
A: AP injury radiograph. B: AP 3-month follow-up radiograph. A loss of reduction with loss of fixation and medialization of the femoral head is evident. Despite the poor radiologic outcome, the patient remained essentially pain-free and active.
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Figure 47-92
Both-column fracture in a 72-year-old man struck by a car.
A: AP injury radiograph. B: AP 3-month follow-up radiograph. A loss of reduction with loss of fixation and medialization of the femoral head is evident. Despite the poor radiologic outcome, the patient remained essentially pain-free and active.
(From Bates P, Starr A, Reinert C. The Percutaneous Treatment of Pelvic and Acetabular Fractures. Dallas, TX: Independent Publisher [IBSN 978-1-4507-3105-8]; 2010, Case 17, pages 169 and 175. Copyright Joe Allred. Permission granted.)
A: AP injury radiograph. B: AP 3-month follow-up radiograph. A loss of reduction with loss of fixation and medialization of the femoral head is evident. Despite the poor radiologic outcome, the patient remained essentially pain-free and active.
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Perioperative Care of Acetabular Fractures

Patients who are in skeletal traction for any length of time prior to their procedure or have prolonged delays until surgery may have an alteration of their skin flora because of the inadequate ability to effectively cleanse the perineum. For this reason, prophylactic antibiotic coverage with a first generation cephalosporin, administered preoperatively and continued at least 24 hours postoperatively, is often supplemented by gram-negative coverage. Suction drainage is used and continued for 48 hours or until drainage has ceased. 
All acetabular fracture patients should be considered at high risk for thromboembolic disease. Currently, no prophylactic treatment consensus exists and clinicians have limited data to guide their prophylactic therapy decisions.165 Our approach is based on evidence-based clinical practice guidelines and consists of mechanical sequential compressive devices applied on hospital admission to both lower extremities, with low–molecular-weight heparin for chemical prophylaxis added as soon as the patient is hemodynamically stable. For patients who require operative intervention, the low–molecular-weight heparin is discontinued on the night prior to surgery. It is usually resumed within 24 hours after surgery, but is delayed if primary hemostasis has not been demonstrated based on examination of the surgical site.60 Despite the possible diagnostic utility of duplex ultrasound screening, it does not seem to decrease the risk of pulmonary embolism in asymptomatic acetabular fracture patients receiving thromboprophylaxis, and the evidence-based clinical practice guidelines recommend against routine duplex ultrasound screening for deep vein thrombosis in asymptomatic pelvic fracture trauma patients unless they have received suboptimal thromboprophylaxis or no thromboprophylaxis.60,128 Therefore, screening is reserved for this select group. Those in this select group who have a preoperative screening test positive for a proximal deep vein thrombosis and those symptomatic patients clinically diagnosed preoperatively with pulmonary embolism or a proximal deep vein thrombosis receive a vena cava filter.60 After discharge from the hospital, the patients are maintained on extended chemical prophylaxis until they have regained an active ambulatory status, usually 6 to 12 weeks postoperatively.13 
Heterotopic ossification is associated with all approaches that involve stripping of muscle from the external surface of the ilium and is a particular risk of extended surgical approaches. Based on a review of the evidence available in the literature, recommendations were made regarding the use of heterotopic ossification prophylactic treatment (Table 47-26).122 In a subsequent systematic review of prospective studies comparing irradiation to indomethacin prophylaxis, an overall rate of heterotopic ossification of 8.9% was found with indomethacin, as opposed to 8.3% with irradiation.14 Although this difference is statistically significant (p = 0.034), the consensus is that this small difference is unlikely to represent a clinically relevant difference.138 In a recent review, indomethacin was again recommended as the primary prophylaxis to prevent heterotopic ossification after acetabular surgery via a posterior or an extended approach.139 Irradiation (as a single dose of 700 to 800 cGy delivered within 72 hours of surgery) should be considered in patients who cannot tolerate nonsteroidal anti-inflammatory agents or have a long-bone fracture considered at risk for nonunion.25,26,138 Indomethacin is given in a dose of 25 mg three times daily beginning within 24 hours of surgery and continued for 4 to 6 weeks. As with other nonsteroidal anti-inflammatory drugs, there are potential gastrointestinal side effects and gastric and duodenal mucosal lesions may occur. Patient compliance has also been found to be a problem. An increased rate of infection has been reported in conjunction with postoperative irradiation.67 
 
Table 47-26
Recommendations for Heterotopic Ossification Prophylaxis
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Table 47-26
Recommendations for Heterotopic Ossification Prophylaxis
1 Prophylaxis after acetabular fracture fixation using the ilioinguinal surgical approach or similar surgical approaches is not recommended.
2 Prophylaxis after acetabular fracture fixation using the extended iliofemoral surgical approach or similar surgical approaches is recommended.
3 Despite conflicting evidence, prophylaxis with indomethacin after acetabular fracture fixation through the Kocher–Langenbeck surgical approach or similar posterolateral surgical approaches is recommended.
4 Prophylaxis with irradiation after acetabular fracture fixation through the Kocher–Langenbeck surgical approach or similar posterolateral surgical approaches is not recommended.
 

After Moed BR, Israel H. Heterotopic ossification prevention and treatment: what is the best way to prevent heterotopic ossification following acetabular fracture fixation? In: Wright JG, ed. Evidence-based Orthopaedics. Philadelphia, PA: Saunders Elsevier; 2009:353–359.

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Postoperatively, AP and oblique postoperative radiographs should be obtained. A postoperative CT scan should be considered if there is concern for inadequate or loss of reduction.70 The patient is mobilized as quickly as the associated injuries will allow. Sitting up on the first postoperative day is followed by formal physical therapy for active range-of-motion exercises on subsequent postoperative days. Total hip arthroplasty precautions should not be needed, as internal fixation has rendered the hip joint stable. Partial, toe-touch weight bearing of 10 to 15 kg with crutches or a walker is required for 10 to 12 weeks. However, progression to full weight bearing must be tailored to the individual. Formal physical therapy should begin at 6 weeks postoperatively for muscle strengthening and continue until muscle strength and range of motion are regained or a plateau is reached. For patients treated using a surgical approach in which the hip abductors are detached at the tendon–bone interface (i.e., the extended iliofemoral approach), active hip abduction, active and passive hip adduction, and hip flexion past 90 degrees are prohibited for at least 6 weeks. 
After discharge from the hospital, patients are seen at 2 weeks for wound inspection and suture removal and then at 6 weeks, 3 months, 6 months, 1 year and postoperatively, and then yearly thereafter. AP and oblique radiographs should be obtained at these visits, early on to assess maintenance of reduction and fracture healing and later to assess the potential for posttraumatic arthritis. The expectation is that patients will return to most routine activities by 6 months postoperatively and more vigorous activities by 1 year. However, multiple elements must be factored into the individual patient’s recovery, including the magnitude of the soft tissue injury, any associated injuries, and the pre-existing medical status. Therefore, the overall recovery time is quite variable. 

Outcomes of Operative Treatment of Acetabular Fractures

Outcomes of ORIF of Acetabular Fractures

Clinical Results of ORIF of Acetabular Fractures.
The results of open reduction and internal fixation of acetabular fractures are varied in the literature and often difficult to interpret. However, three of the largest series reporting outcomes after acetabular fractures treated within 3 weeks of injury all reported good or excellent results in 75% to 81% of fractures at long-term follow-up.9,107,112 As previously noted, the instrument used in the assessment of acetabular fracture outcome has been a clinical measure, the modified rating scale of Merle d’Aubigné and Postel.93,102,120,121 To reiterate, this scale rates pain, walking, and range of motion each on a 6-point scale. A score of 18 is excellent, 17 is very good, 16 and 15 are good, 14 and 13 are fair, and less than 13 is poor (Table 47-4). The scores are usually dichotomized into good-to-excellent (15 to 18) and fair-to-poor (14 or less) groups for reporting purposes. 
One of the objectives of operative intervention is to obtain an anatomic reduction of the articular surface, and clinical outcome strongly correlates with the adequacy of fracture reduction.93,107 In Letournel and Judet’s series of 492 acetabular fractures treated operatively, anatomic reduction was achieved in 366 patients (74%). Eighty-one percent of patients demonstrated a good, very good, or excellent result using their modification of the Merle d’Aubigné and Postel hip score.93 In contradistinction, approximately 64% (81 of 126) of patients with an imperfect reduction achieved a good-to-excellent clinical result. Posttraumatic arthritis was observed in 10% of cases where anatomic reduction was achieved and in 36% of cases where reduction was imperfect.93 Even when posttraumatic arthritis was seen after a perfect articular reduction, Letournel and Judet93 found that 50% of the time, the arthritis presented between 10 and 25 years after injury. In contrast, after imperfect reduction, 80% of the cases of arthritis appeared within the first 10 years after injury. 
Matta107 also demonstrated the importance of achieving an anatomic reduction (defined as up to 1 mm of residual displacement) as the main outcome determinant for acetabular fracture surgery. Two hundred and sixty-two patients with displaced acetabular fractures treated operatively were evaluated at an average follow-up of 10.9 years. Interestingly, he obtained results that were essentially identical to those of Letournel and Judet. Eighty-one percent (150 of 185) of patients with anatomic reduction achieved a good or excellent clinical result, whereas only 64% (49 of 77) of patients with nonanatomic reduction achieved a good or excellent clinical result.107 An important difference between those with an anatomic reduction and those with an imperfect reduction (defined as 2 to 3 mm of residual displacement and previously called “satisfactory”) was demonstrated. Therefore, from these clinical results it would appear that to maximize the patient’s hip function following injury, the surgeon must strive for an inframillimetric reduction with every fracture. 
The rate of anatomic reduction has been shown to decrease with increased fracture complexity, patient age, and time delay to fracture fixation.107 Time delay to fracture fixation dramatically affects results. In Letournel and Judet’s series of 138 patients treated after a 3-week delay, the rate of good-to-excellent results dropped to 54%.93 Similarly, Johnson et al.77 reported 65% good-to-excellent results in 187 patients. In a series of 237 patients, Madhu et al.100 found that an anatomic reduction was more likely if surgery was performed within 15 days for elementary fracture types and 5 days for associated fracture types. A good-to-excellent clinical outcome was more likely when surgery was performed within 15 days for elementary fracture types and within 10 days for associated fracture types. In general, anatomic reductions are more difficult to obtain in the morbidly obese.146 
Certain fracture patterns appear to have better outcomes after surgical treatment than others (Table 47-27). Both-column fractures are complex injuries and technically demanding. However, they have a generally better outcome than many fracture types, despite a higher rate of nonanatomic reduction. Matta107 obtained anatomic reduction in only 57% of cases, yet still achieved a good-to-excellent result in 77%. Posterior wall fractures present as a straightforward treatment problem with excellent anatomic reduction rates reported as high as 100%.107 However, despite the anatomic reduction obtained in all 22 treated fractures, a 32% clinical failure rate was reported.107 This was higher than for any other fracture type in the series. Similar findings have been reported by Aho et al.1 and Chiu et al.31 However, others have reported clinical results (more than 80% good-to-excellent) similar to other acetabular fracture types.52,93,121 It was suggested by Letournel and Judet93 and later shown by Moed et al.120 that the disparity between clinical results and apparent anatomic reduction, as determined by plain radiography, is due, in large part, to the inadequacy of radiographs in assessing the quality of the postoperative posterior wall reduction. In this series of Moed et al., fracture reductions were graded as perfect in 65 and imperfect in 2 (97%), as determined with use of plain radiography.120 However, postoperative CT revealed the articular surface reduction to be perfect in only 15 (22%).120 Postoperative CT, therefore, appears to be a more accurate means of documenting the articular reduction after posterior wall fracture.17,120 However, because of recent concerns raised regarding the radiation exposure from repeated CT examinations, routine postoperative CT scanning is not warranted unless it is being used for a medical need, such as to evaluate possible loss of reduction or fixation requiring reintervention.21,149 
 
Table 47-27
Results of Operative Management of Acetabular Fractures
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Table 47-27
Results of Operative Management of Acetabular Fractures
Clinical Results
Fracture Type Excellent Very Good Good Fair Poor Total Percent Excellent Results
Posterior wall 87 6 3 4 17 117 74%
Posterior column 9 0 1 1 0 11 81.82%
Anterior wall 6 0 1 1 1 9 66.67%
Anterior column 12 1 1 0 2 16 75%
Transverse 17 1 0 0 1 19 89.47%
T-shaped 20 3 0 0 3 26 76.92%
Transverse and posterior wall 49 16 10 9 17 101 48.51%
Posterior column and posterior wall 5 1 2 1 8 17 29.41%
Anterior column and posterior hemitransverse 26 5 4 3 3 41 63.41%
Both-column 76 21 14 11 13 135 56.3%
Total 307
62.4%
54
10.98%
36
7.32%
30
6.1%
65
13.21%
492
100%
62.4%
 

(From Letournel E, Judet R. Fractures of the Acetabulum. 2nd ed. Berlin: Springer-Verlag, 1993.)

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Functional Outcomes of ORIF of Acetabular Fractures.
Studies using the MFA outcome instrument as the evaluative measure of health status after acetabular fracture surgery paint a different picture than those evaluating hip function using the modified Merle d’Aubigné and Postel clinical score.87,127,131 In a series of studies, Moed et al. found that complete recovery after a fracture of the acetabulum is uncommon, with residual functional deficits involving wide-ranging aspects of everyday living that do not necessarily have an obvious direct connection to hip function.127,131 Although a correlation was found between the modified Merle d’Aubigné and Postel score and the MFA score, the relatively worse MFA scores for these patients with an acetabular fracture, compared with those in the reference population, indicate that a complete return to a preinjury functional level is uncommon for these patients despite a good-to-excellent Merle d’Aubigné and Postel clinical score.127,131 Similarly, Kreder et al.87 found relatively worse MFA scores for patients with an acetabular fracture compared with those in the reference population. Despite some differences among these studies, the overall data and the importance of the emotional category of the MFA score as a negative determinant of functional outcome were consistent. Interestingly, these findings are similar to those of a small series of patients with hip and femur fractures.43 Although the modified Merle d’Aubigné and Postel score may be useful for evaluating isolated hip function in patients with a fracture of the acetabulum, it appears to have limited usefulness as a method for evaluating the overall functional outcome in these patients. These findings indicate that it certainly is possible for a patient to have minimal hip pain, walk without a limp, and have a good-looking radiograph but not be doing well. 
Despite the fact that there have been concerns raised regarding the validity of the reference values of the MFA score,113 others have reported similar functional limitations in acetabular fracture patients using different functional outcome instruments.15 Investigators using the Short Form-36 and Life Satisfaction-11 to evaluate quality of life in 136 operatively treated acetabular fracture patients and followed for at least 2 years found that life satisfaction plateaued at 6 months and was generally lower than normal.15 Furthermore, they found that Short Form-36 outcome improved in the physical domains over a 2-year period; however, remained lower than normal.15 Importantly, patients having an anatomic fracture reduction scored better than those with residual displacement of >2 mm.15 
As previously noted, acetabular fracture patient outcome also has been evaluated using survivorship of the hip, with conversion to total hip arthroplasty or hip fusion as an indirect indication of the development of posttraumatic osteoarthritis.48,178 Evaluation of 816 hips treated by open reduction and internal fixation available for follow-up showed a cumulative survivorship of 79% at 20 years.178 Factors were identified that were predictive of the need for early conversion (see section Operative Treatment Indications/Contraindications). 

Outcomes of Percutaneous Treatment of Acetabular Fractures

Clinical Results of Percutaneous Treatment of Acetabular Fractures.
Currently, there are very little long-term follow-up data demonstrating clinical results in these patients. Most series have a very small number of patients with little or no follow-up.23,51,81,145 In one of the larger series, Starr et al.168 reported on 24 patients. Thirteen elderly patients with displaced fractures had medical problems and anatomic fracture reduction was not thought to be a necessity. There were also 11 young patients with minimally displaced elementary fracture patterns. Closed or limited open reduction was thought to be successful in 23 patients. In one obese young patient, the percutaneous surgery was aborted and an open procedure was performed. Postoperatively, average residual articular displacement as measured on plain radiographs was 3 mm in the 13 elderly patients and 1 mm in the 10 young patients. After an average of 1 year of follow-up, 5 of the 11 elderly patients available for follow-up had already undergone total hip arthroplasty and there were incomplete data reported for the 10 young patients.168 Unfortunately, the Harris Hip Score was used for the clinical evaluation of these patients, precluding comparison with other studies using open reduction and internal fixation. In a follow-up from this center, the investigators reviewed their first 18 patients over the age of 60 years with displaced acetabular fractures treated with closed or limited open reduction and percutaneous screw fixation.160 All 18 fractures were reduced to within 5 mm with minimally invasive techniques, and stabilized percutaneously and followed for a mean of 27 months. Four patients experienced early loss of reduction. Of these four, two had total hip arthroplasty within 1 year and one died of unrelated causes. Three additional patients died and two of the remaining eleven patients progressed to total hip arthroplasty. In a more recent study from this center, a review of 35 patients over the age of 60 years followed from 2 to 15 years showed that 24 had maintained their native hip and 11 had been converted to total hip arthroplasty.49 Again, the Harris Hip Score. Based on these limited clinical results, it is difficult to provide any specific recommendations regarding this technique. 
Functional Outcomes of Percutaneous Treatment of Acetabular Fractures.
In the recent study noted above,49 functional outcomes were obtained in 35 patients aged 60 or older treated at an average of 6.8 (range 2 to 15) years after the index surgery using the Short Form Musculoskeletal Functional Assessment outcome instrument. Although the outcome results showed no difference from the population norms for individuals over the age of 60, the patient numbers were small and the poorer patient scores for the daily activities and mobility indices approached levels of significance.49 
Survivorship of the native hip joint has been evaluated after percutaneous repair of acetabular fractures in the elderly.48 In 75 patients aged 60 or older, treated with percutaneous reduction and fixation of acetabular fractures, and followed for a mean of 3.9 years (range 0.5 to 11.9), 19 had total hip replacements. Survivorship analysis demonstrated a cumulative survival of 65% at 11.9 years and there were no conversions to arthroplasty beyond 4.7 years postoperatively. Based on these findings, these investigators concluded that rate of conversion to total hip arthroplasty is comparable to open treatment methods and if conversion is required, soft tissues are preserved for future surgery.48 

Management of Expected Adverse Outcomes and Unexpected Complications in Acetabulum Fractures

Posttraumatic Arthritis and Osteonecrosis of the Femoral Head in Acetabulum Fractures

The primary complication after fracture of the acetabulum is posttraumatic arthritis. The quality of the fracture reduction appears to be the main determinant for the risk of late traumatic arthritis.93,107,112 Long-term studies have demonstrated that fracture reductions to within 1 mm of residual displacement have better long-term outcome and a lower prevalence of arthritis than those with greater than 1 mm of displacement. In addition, if arthritis develops after a perfect reduction, the onset tends to be later and the progression slower than arthritis that develops after a poor reduction.93 Damage to the femoral head at the time of initial injury is another important factor.107 Osteonecrosis of the femoral head is known to result from acetabular fracture associated with hip dislocation and can be a cause of posttraumatic arthritis. However, posttraumatic arthritis more commonly occurs because of wear of the femoral head against a malreduced fracture and may often be incorrectly attributed to osteonecrosis.93,107 Conversion to total hip arthroplasty or hip fusion should be dictated by the clinical symptoms and functional needs of the individual patient. 

Infection in Acetabulum Fractures

The rate of infection is approximately 5% in most series of acetabular fractures treated operatively.93,107,112 The risk of infection is increased in patients with open fractures and local soft tissue injuries such as Morel–Lavallé lesions (Fig. 47-93).62 Gastrointestinal or urologic injuries are also associated with increased infection rates. Appropriate antibiotics, less extensive surgical approaches, and aggressive debridement of open wounds can help to decrease the rate of infection. As previously noted, Haas et al.61 reported infection in 6 of 66 (9%) patients who were treated with postoperative irradiation to diminish heterotopic ossification. This is one of the highest reported rates of infection after acetabular fracture. However, other authors have reported lower rates of infection after extended approaches and irradiation.123,170 Embolization of a pelvic arterial injury has also been found to be associated with a high rate of infection after subsequent open reduction and internal fixation of an acetabular fracture.102,158 In one series, 58% of the patients (7 of 12) who underwent embolization subsequently became infected and a disproportionate number of patients who developed infection had their entire internal iliac artery embolized.102 They concluded that embolization of the entire iliac artery should be avoided whenever possible. Morbidly obese patients have been found to be five times more likely to develop a postoperative wound infection when compared with their normal-weight counterparts.83,147 
Figure 47-93
Example of a Morel–Lavallé lesion in a patient with combined pelvic and acetabular fractures.
(Copyright Berton R. Moed, MD.)
(Copyright Berton R. Moed, MD.)
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The adverse effect of a deep postoperative intra-articular wound infection cannot be minimized. Complete joint destruction can be expected in 50% of these cases.107,112 However, the results are somewhat dependent on the surgical approach. If an infection involves the joint itself, the results are uniformly bad. This is usually the case when a surgical approach is used that exposes the joint directly, such as the Kocher–Langenbeck or an extended approach. In contradistinction, patients treated operatively via the ilioinguinal approach who become infected have a much better chance at a good outcome. This is likely because there is less devitalization from stripping of muscle from the innominate bone and the reduction of the joint is indirect. Therefore, the local blood supply is less impaired and deep infection may remain extra-articular, sealed off from the joint by the fracture reduction and healing. 
Management of infection is similar to that for other anatomic regions. If the infection is early, then hardware preservation is attempted to maintain the stability of the hip until union; then it is removed. Early recognition is important. Excessive wound drainage should be aggressively managed by exploration of the wound, irrigation, debridement, and closure over drains. Culture-positive wounds should be treated with repeat irrigation and debridement until the wound is fully controlled and definitive closure is possible. Late infection is treated with hardware removal. In all cases, a long-term culture-specific antibiotic, usually with a minimal empiric course of 6 weeks, is used. 

Iatrogenic Nerve Injury in Acetabulum Fractures

Although the superior gluteal, inferior gluteal, obturator, or femoral nerves may be injured during acetabular surgery, the known prevalence of these injuries is low. However, iatrogenic damage to the sciatic nerve is one of the major complications encountered in acetabular fracture management. These injuries are most commonly associated with the posterior and extended surgical approaches that involve direct exposure and retraction of the sciatic nerve.93,186 Injury at the time of indirect reduction of posterior column displacement through an anterior surgical approach can also occur.39,74,93 The rate of nerve injury appears to decrease as surgeon experience increases. Matta et al. reported a 9% prevalence in their retrospective series, decreasing to 5% in the subsequent prospective series, and further diminished to 3% without the aid of any nerve monitoring.106108 These numbers compare favorably with those of series using somatosensory evoked potential monitoring systems that report a 2% to 7% prevalence.11,68,74,186 The question is whether somatosensory evoked potential monitoring, although feasible, is of real clinical value. It has been shown that iatrogenic injury may occur despite normal somatosensory evoked potential tracings.124,186 Furthermore, Middlebrooks et al.118 demonstrated no substantial reduction in the rate of iatrogenic nerve injury with the use of intraoperative somatosensory evoked potential monitoring. At present, there are no clear data indicating that nerve monitoring actually reduces the overall rate of iatrogenic sciatic nerve injury. Currently, regarding the prevention of this complication, there is no substitute for attention to detail in the operating room with careful patient positioning, maintaining the knee flexed during posterior approaches to relax the sciatic nerve, cautious placement of retractors, and limited traction on the nerve during fracture reduction. 
Management of sciatic nerve injury is expectant and as previously noted, the prognosis for functional recovery is variable, depending on the degree of involvement of the peroneal division.45 Electromyography is helpful in defining the extent and severity of injury but not as a prognostic indicator.45 Return of nerve function occurs over a variable time interval with recovery noted as late as 3 years after surgery.93 Management of sciatic nerve injury consists of the use of an ankle-foot orthosis, observation, and physical therapy. Medical treatment may be required to control the pain of neurogenic origin.45 Prolonged sciatic neuropathy associated with acetabular fractures can result in disabling long-term symptoms. Release of the sciatic nerve from scar tissue and heterotopic bone has been shown to be helpful.76 Decrease in the sensory symptoms can be expected; however, motor symptoms are less likely to resolve.76 
Iatrogenic injury to the femoral nerve is very rare with a prevalence of 0.2% to 0.4%.58,93,107 Unfortunately, the impairment can be debilitating, with the patient often requiring bracing for ambulation. Fortunately, with the exception of the highly unusual occurrence of laceration of the nerve, the prognosis for recovery is excellent.58 The most common neurologic injury after treatment of an acetabular fracture is to the lateral femoral cutaneous nerve after the ilioinguinal approach.37,96,111 Despite taking all appropriate measures to protect the nerve, during even a routine surgery the nerve may become stretched or attenuated. Clinically, most patients experience a region of cutaneous anesthesia in the nerve distribution that becomes dysesthetic over time but ultimately resolves. Warning the patient of this likelihood preoperatively is important because even though the symptoms are generally well tolerated by the patient, they are nevertheless bothered enough by their symptoms to seek reassurance that they will resolve or be mitigated over time. 

Venous Thromboembolism in Acetabulum Fractures

As previously mentioned, posttraumatic and postoperative thromboembolism is a significant problem in acetabular fracture patients. Letournel and Judet93 reported 13 deaths (2.3%) after acetabular fracture surgery, 4 of which were caused by massive pulmonary embolism. In a more recent series of 229 patients treated using a thromboprophylaxis regimen, symptomatic postoperative deep vein thrombosis occurred in 4% and symptomatic postoperative nonfatal pulmonary embolism occurred in 1%.128 There were no fatal cases of pulmonary embolism. Patients diagnosed preoperatively with pulmonary embolism or a proximal deep vein thrombosis are candidates for the insertion of a vena cava filter.60 

Intra-articular Hardware in Acetabulum Fractures

Although specific rates are not available, intra-articular placement of screws is a documented and often destructive complication of acetabular fracture surgery. Letournel and Judet93 originally proposed taking the hip through range of motion in complete silence in the operating room to listen for crepitus as a method for detecting intra-articular hardware. Anglen and DiPasquale6 recommended the use of a sterile esophageal stethoscope for the same purpose. Other authors have recommended careful intraoperative and postoperative radiography (fluoroscopy, plain radiography, and/or CT) to ensure that the hardware has been placed outside the joint.6,40,140 However, intraoperative fluoroscopy is the best method.29 At the completion of the operative procedure, the hip joint should be completely examined using C-arm fluoroscopy. Axial and tangential views should be obtained of any screws near the joint to ensure extra-articular placement. Screws having questionable position should be repositioned. If this intraoperative examination has not been performed and postoperative examinations indicate intra-articular compromise, the patient should be returned to the operating room and the offending implant(s) should be removed. Otherwise, posttraumatic arthritis will almost certainly ensue. 

Heterotopic Ossification in Acetabulum Fractures

The radiographic occurrence of heterotopic ossification is quite common after acetabular fracture surgery. It has been reported as occurring in as many as 90% of patients after acetabular fracture surgery (range, 18% to 90%) with severe involvement as high as 50% in some patient groups.19,114 The terminology “severe heterotopic ossification” is often used to describe the amount of heterotopic ossification necessary to impair function. Greater than 20% loss of total hip motion is thought to be the best clinical definition for severe heterotopic ossification.107 Many reports have used the Brooker classification, which relies solely on the AP radiographic view of the hip, for this determination.19,114,125 However, this radiographic method does not consistently correlate with hip joint motion and generally overestimates the clinical severity of heterotopic ossification.93,129,133 Although adding the standard Judet oblique views (which would routinely be obtained in the course of the patient’s postoperative evaluation) to the AP view has been shown to give a more reliable indication of the restriction of motion that can be attributed to heterotopic ossification,129 this method has not attained general use. The study reported by Matta,107 in which significant heterotopic bone formation was defined as motion limited by greater than 20% and patients were not given prophylactic treatment, provides the expected prevalence figures for clinically important heterotopic ossification. These figures are as follows: Kocher–Langenbeck, 9 of 112 (8%); extended iliofemoral, 12 of 59 (20%); and ilioinguinal, 2 of 87 (2%).107 
Symptomatic heterotopic ossification requires surgical excision, generally followed by secondary prophylaxis for recurrence prevention.138 Traditionally, this treatment was thought to require delay until normalization of alkaline phosphatase levels, stable or diminishing bone scan activity, and maturation of the heterotopic bone on radiographs. More recently, early excision following fracture healing and adequate rehabilitation has been recommended.138 However, further data on this treatment is needed. Whatever the timing of surgical excision, preoperative planning using standard two-dimensional axial sections, as well as three-dimensional reconstructions, is important to define the surgical approach for bony excision and to help identify the location of neurovascular structures. Single-dose postoperative irradiation therapy or indomethacin is used for postexcision prophylaxis.138,192 Surgical excision is a very successful treatment modality in patients with congruent joint surfaces. Significant relief of pain and return of motion should be expected in the great majority of patients.93,114,133,138,189,192 

Authors’ Preferred Treatment for Acetabulum Fractures

 
 

Nondisplaced fractures, excluding those involving the posterior wall, can be treated by close observation (Fig. 47-94). Any evidence of subsequent fracture displacement necessitates operative intervention. Nondisplaced posterior wall fractures should be evaluated with stress examination under anesthesia. Instability demonstrated with this examination warrants open reduction and internal fixation. Stable nondisplaced fractures can be treated nonoperatively. Displaced fractures require operative treatment, preferably open reduction and internal fixation. As detailed in the foregoing sections, the specific surgical tactic is dictated by many factors, the most important being the exact fracture morphology.

 
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Figure 47-94
Authors’ preferred treatment approach.
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Summary, Controversies, and Future Directions in Acetabulum Fractures

Since the initial publications of Judet and Letournel in the early 1960s, significant strides have been made in the treatment of acetabular fractures. There is no doubt that excellent clinical results can be obtained by experienced surgeons, and the expansion of educational activities specific to acetabular fracture care has increased the number of experienced surgeons. However, acetabular fracture fixation remains an extensive surgery with a significant potential complication rate. The results of Letournel and Judet (1993) remain the “gold standard.” 
Not all patients achieve a good or excellent clinical result, related mainly to residual fracture displacement and perioperative complications. In addition, not all fractures are perfectly reconstructable, and there are some patients for whom the operative morbidity may not be justified, given the expected result. Fractures complicated by osteopenia, pre-existing arthritis, large degrees of articular impaction, or morbid obesity continue to routinely fail current open reduction and internal fixation techniques.5,72,83,146,147,166 Elderly patients with significant medical comorbidities may not tolerate an extensive reconstructive procedure and may not be able to comply with the postoperative weight-bearing restrictions. Some of these patients perhaps would be better served initially with total hip arthroplasty, percutaneous fixation, or nonoperative management. Use of the suggested nomogram (Fig. 47-39) may help to define patients better suited for alternative treatments.178 Unfortunately, the outcomes from these alternative techniques are themselves suspect. Primary arthroplasty to treat acetabulum fracture has been associated with a significantly higher complication rate and poorer outcomes than standard primary arthroplasty.63,115,137,180 The early results of percutaneous treatment are encouraging.48,49 Nonoperative treatment alone has been shown to be generally ineffective with 30% of patients reported as having a poor result.166 Total joint arthroplasty following initial nonoperative treatment also has not been shown to have long-term success as compared with routine total joint arthroplasty for osteoarthritis.154 Accepting the fact that patients at great risk for failure with open reduction and internal fixation can be identified preoperatively, further work to evaluate and improve treatment alternatives is needed. 
The advent of CT-derived, reconstructed radiographs offers the potential of obtaining the radiographs needed for diagnosis without the usual bother to the patient or the treating surgeon. It remains to be seen whether these studies, or improved volume-rendered three-dimensional studies, can provide information equivalent to, or better than, that derived from plain radiographs (Fig. 47-11). More information is also needed regarding the determination of joint stability for both posterior wall fractures and nondisplaced fractures that have the “potential” to displace. However, the most controversial area of acetabular fracture treatment is determining the place for percutaneous surgery. Its place as an alternative treatment for the elderly, for the morbidly obese, for “potentially unstable” nondisplaced fractures, and as a staging procedure for total hip arthroplasty awaits further study. 

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